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OPhthalMOlOgY 




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Ophthalmology Curriculum 
1. Overall Aims Of Course: 

• Diagnosis of common ophthalmic diseases in the community . 

• Provide ophthalmic çare to community . 

• Management of lry health centres . 

• Provide health education of preventive measures to common ophthalmic diseases 
.5- Knovvledge & use of the statistical data of ophthalmic diseases to improve 
community health . 

2. 1 ntended Leaming Outcomes Of Course (I LOS): 

1. Knovvledge & Understanding: 

1. Ophthalmic diseases that can be managed by the general practitioner . 

2. Ophthalmic diseases that should be transferred to a specialist a3- Ocular 
emergencies & how to start the İst aid . 

2. IntellectualSkills: 

1. Problem solving of case studying of common ophthalmic diseases 

2. Relationship betvveen eye & body disorders . 

3. Investigations related to ophthalmology. 

3. Professional & Practical Skills: 

1. General ophthalmological examination . 

2. Examination of the anterior segment of the eye 

3. Methods of simple manoevers e.g foreign body removal. 

4. General & Transferable Skills: 



1. Computing skills 

2. Communication skills 

3. Managereal skills( planning ,budging 
)■ 

3. Contents (per vear) 



decision making , negotiation & marketing 



Topic 

Ocular examination 
The eye lid 
The lacrimal system 
The dry eye 
The cojunctiva 
The cornea 
The sclera 


No. of hours Lecture Tutorial/ Practical 

5 1 4 

6 2 4 
2 1 1 
2 1 1 
6 2 4 
6 2 4 
2 1 1 



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The uveal tract 

The lens 

Glaucoma 

Red eye 

Neuroophthalmology 

The retina 

The optic nerve 

Intraocular tumours 

Errors of refraction 

Squint 

Ocular pain & headache 

The orbit 

Ocular injuries 

Ocular emergencies 

Laser in ophthalmology 

Total 




87 



31 



4. Teaching & Leaming Methods: 

1. Lectures 

2. Tutorials 

3. Clinical examinations 

4. Slides 



5. Student Assessment: 



Assessment methods: 







1. VVritten exams.: short essays & MCQs to assess : intellectual skills 

2. Clinical examsto assess : clinical skills. 

3. Slides . to assess : clinical & intellectual skills 

4. Oral exams to assess :knowledge & understanding 

Assessment schedule: 



1. Assessment 1 

2. Assessment 2 

3. Assessment 3 

4. Assessment 4 




MCQs Week 8th 

Slides week 8th 

Cases & slides final clinical exam. 

Essays : final vvritten exam 



Weiqhtinq of Assessments: 



Mid-Term Examination % 
Final-term Examination 20 % 
Oral Examination. 12 % 
Practical Examination 12 % 
Semester Work % 
Other types of assessment 66 % 



7. Total 100% 

6. List of References: 

1. Course Notes 

2. Essential Books (Text Books) 

Spotlight on Ophthalmology : vvritten by staff members of the department 

3. Recommended Books 

Clinical Ophthalmology Kanski 

4. Periodicals, Web Sites, ... ete 

7. Facilities Reguired ForTeaching And Leaming: 



1. Data projectors 

2. Slide projectors 

3. Out-patient elinic 

4. Lecture halis 




EYE LID 



1-Comment on the aetiology, C/P &ttt of stye 

2-Discuss the aetiology of entropion. 

3-What are the causes & management of cictricial entropion of the upper lid? 

4-Describe the various types of entropion & their Management 

5-Discuss entropion of the lower lid, C/P & management 

6-What is ptosis, Describe its various types? 

7-Discuss causes of ptosis, Mention its ttt? 

8-Discuss the aetiology & ttt of trichiasis. ? 

9-Give an account on chalazion of the lid. ? 

10-What are the clinical types of ectropion, Describe the C/P? 




GLAUCOMA 



1-Give an account on medical ttt of acute congestive glaucoma? 

2-What is differential diagnosis of acute 1ry congestive glaucoma? 

3-discuss the ttt of acute congestive glaucoma? 

4-What is the management of congestive glaucoma? 

5-What is meant by 2rt glaucoma, discuss its causes? 

6-How can affection of the crystalline lens causes 2ry glaucoma? 

7-Explain how may iritis lead to 2ry glaucoma? 

8-A 50-year-old female developed rapid diminution of vision in her right eye,which is red, 

tender & has photophobia: 

*Enumerate the possible causes. 

*How can you differentiate between the different Causes? 

*How can this patient lose her vision? 
9-How can you proceed to diagnose a case of POAG, What are the factors that affect 

the prognosis? 
10-How can you treat a case of POAG? 
11 -Discuss the management of acute congestive glaucoma" elosed angle 

glaucoma" 



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RETİNA & OPTIC NERVE 



1-Comment briefly on 1ry retinal detachment? 
2-Give an account on CL/P of retinitis pigmentosa? 

3-What are the serious intraocular complications of long standing DM? 



4-What are the fundus changes in DM? 

5-Describe the CL/P & ttt of diabetic retinopathy? 

6-What are the clinical types of Optic atrophy and their causes? 

7-Give an account on papilloedema? 

8-Write notes on CRVO? 

Conjunctiva 



1-Describe the etiology,C/P,complication and medical ttt of trachoma. 

2-discuss clinical picture of trachomatous pannus. 

3- what are the signs,symptoms,complications and ttt of purulent conjunctivitis. 

4-describe the managemrnt of acute congestive mucopurulent conjunctivitis. 

5- discuss the etiology, clinical picture, and possible complication of bacterial 

mucopurulent conjunctivitis. 

6-discuss the prophylaxis,complication and ttt of ophthalmia neonatorum. 

7-discuss the management of a case of acute memberanous conjunctivitis. 

8-discuss the clinical picture of vernal conjunctivitis"spring catarrh" ,give an account on 

its ttt. 

9-as regard pannus: 

* give the definition of corneal pannus. 

* what are different types of pannus. 

* discuss the type of the commenest pannus in Egypt. 
10-discuss the clinical picture,complication and management of phylectenular 
keratoconjunctivitis 



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Lacrimal 



1 . comment on xerosis 



2. how would you manage acute dacryocystitis. 

3. VVhat's the etiology.CL/P and complication of chronic dacryocystitis. 

4. Describe the management of lacrimal fistula 

5. How would you investigate a patient suffering from watering of his eyes? 

6. Discuss causes of watering of the eye in a newborn. 

THE ORBIT 

1-what are the causes and complication of orbital cellulites? 

2-Give short account on causes of unilateral proptosis. 



CORNEA 



1-Comment on dendritic corneal ulcer. 

2-What is the management of tow serious complications of hypopyon corneal ulcer? 

3-Discuss aetiology, C/P & ttt hypopyon corneal ulcer. 

4-Describe the complication of perforation of a small central ulcer 

5-How can corneal affection causes defective vision? 

6-Discuss complications of corneal ulcer? 



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UVEAL TRACT 



1-What are the types & complications of iridectomy? 

2- Discuss the ttt of acute iritis, How can acute iritis produces 2ry glaucoma? 

3-Discuss the clinical picture & ttt of acute iritis. 

4-A patient has circumcorneal ciliary injection in one eye, What are the possible 

causes, How can you differentiate between them? 
5-Discuss the signs & symptoms of diseases causing ciliary injection. 
6-A child 5 years old presented with red eye, Enumerate & differentiate the possible 

causes 

7-Give an account the causes, signs, symptoms, complications & ttt of acute 

iridocyclitis. 
8-Write short notes on panophthalmitis. 
9-Write short notes on supp. Endophthalmitis. 








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THE LENS 



1-Describe the management of lamellar cataract. 

2-What are the signs of intumescent senile cataract. 

3-Discuss the signs & complication in immature senile cataract, Give an account on 

ant. Polar cataract. 
4-Describe the CL/P & ttt of diabetic changes in the lens 
5-How would you diagnose & a case of senile cataract? 
6-What are the signs of surgical aphakia, Give an account on its ttt. 
7-What are the commenest tow causes of bilateral, gradual failure of vision in a healthy 

60 years patient with emmetropic eyes, comment on the ttt of one of them 

8- Comment on monocular aphakia. 

9- Discuss on the histology of the lens. 

10-Discuss the clinical picture of different stages of senile cataract comment briefly 
on its ttt. 



EYE INJURIES 



1 -Discuss the effects of blunt trauma on the ant. Segment of the eyeball 

(cornea, A.C., iris, ciliary body & lens) 
2-Discuss the possible mechanisms by blunt trauma to the eye induces rise of IOP 
3-Write short notes on the effect of blunt trauma on the iris. 
4-Enumerate the complications that occur in the eyeball following trauma by a tennis 

bali 
5-What are the complications & ttt of traumatic hyphaema. 
6-Comment on ocular lime burn. 



ERRORS OF REFRACTION 



1 -Comment on presbyopia. 

2-Comment on hperopia. 

3-Mention the various types of astigmatism. 

4-Give the ttt of irregular astigmatism. 

5-What are the types, complications & ttt of myopia. 

6-A high myopic patient developed rapid drop of vision in one e\ 

* What are the possible causes of drop vision? 

* Enumerate the types of myopia. 

* Describe the signs seen in the fundus of the other eye. 
7-Discuss causes of errors of refraction. 




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SOÜINÎ 




1-What are the signs of sixth nerve palsy? 
2-Give short account on ocular headache. 
3-Discuss the types and diagnosis of latent squint. 
4-Comment on: 
* Cover test. * Asthenopia 



TUMORS 



1 -Comment on retinoblastoma. 



THE FIELD 



1-Give an account on methods of recording the field of vision. 
2-Give an account on Scotoma. 



3-Enumerate the various methods of examining the field of vision & and comment on 
their clinical application, what meant by the term positive, negative, relative & 
absolute Scotoma. 

THEPUPIL 

1-What are the causes of unilateral dilated pupil? 

2-Explain the normal reaction of the pupil to light. 

3-What are the anatomical bases of the different types of hemianopia. 

4-Discuss the characters of the pupil in the following conditions: 

* Optic neuritis. 

* Complete 3 rd nerve palsy. 

* Argyl Roberston pupil. 

* Iritis. 

5-What are the anatomical & physiological characters of the normal pupil? 
6-Discuss the importance of the size of the pupil. 

VISUAL ACUITY 



1-Write short notes on evaluation of visual acuity in infant and children. 

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Mnemonics 



M nem o n i c : something that is designed to assist the memory (often referring to a word or 
group of vvords that can be associated with the information being remembered 



Associations of Vortex 
Keratopathy: ABCD 

submitted by Philip Alexander (source of 
list: Kanski) 

Arthritis (diclofenac) 
Breast Cancer (Tamoxifen) 
Cardiac (amiodarone) 
Dementia / Depression 
(Chlorpromazine) 
Enzyıme deficiency (see F) 
Fabry's Disease 



Features of Keratoconus: CONES 

Submitted by Jim McHugh (source of 
list: Kanski) 

Central scarring & Fleischer ring 
Oil drop reflex / Oedema (hydrops) 
Nerves prominent 
Excessive bulging of lower lid on 
dovvngaze (Munson's sign) 
Striae (Vogt's) 



System ic associations of 
keratoconus: ABCDEF 

Submitted by Jim McHugh (source of 
list: Kanski) 

Atopy 

Bones (osteogenesis imperfecta) 

Crouzon's syndrome 

Dovvn's syndrome 

Ehler's Danlos syndrome 

Fingers (Marfan's) 

Stromal dystrophies: Marilyn Monroe 
Always Gets Her Man in LA City 

submitted by Philip Alexander (source of 
mnemonic: www.mrcophth.com) 

Macular dystrophy 
Mucopolysaccharide 
Alcian blue 



Granular Dystrophy 
Hyaline material 
Masson's Trichrome 
Lattice Dystrophy 
Amyloid 
Congo Red 

Features of Post Enucleation Socket 
Syndrome (PESS) 

Submitted by Philip Alexander (source 
of mnemonic: Cornelius Rene, 
Consultant Ophthalmologist) 

Ptosis 

Enophthalmos 
Deep upper Sulcus 
Slack lower lid 



Secondary glaucoma: NIPPLES 

Submitted by Jim McHugh (source of 
list: Kanski) 

Neovascular 

Iridoschisis 

PXF 

Pigmentary 

Lens (phacolytic/phacomorphic) 

Iridocorneal Endothelial 

syndromes 

Seclusio pupillae (in iritis) 

+trauma (angle recession) 

Iridocorneal Endothelial (ICE) 
Syndrome subtypes: ICE 

Submitted by Philip Alexander 
Source of mnemonic: American 
Academy Series (Pathology and 
Intraocular Tumours) 

İris Naevus 
Chandler Syndrome 
Essential İris Atrophy 

Causes of cataract: DAMAGED 



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Submitted by Jim McHugh (source of 
list: Kanski) 

Diabetes 

Atopy 

Myopia / Myotonic dystrophy 

Anterior uveitis (chronic) 

Glaucomflecken 

Electricity / radiation / trauma 

Drugs / Dystrophies 

Drugs causing cataract: ABCD 

Submitted by Jim McHugh (source of 
list: Kanski) 

Amiodarone 
Busulphan 
Chlorpromazine 
Dexamethasone (po/g) 

Causes of ectopia lentis: ECTOPIC 
M&M 

Submitted by Jim McHugh (source of 
list: Kanski) 

Eye degeneration (phthisis) 

Choroidal tumours 

Trauma 

Overstretched zonules (buphthalmos / 

megalocornea) 

AR with Pupil ectopy 

Isolated AR 

Cystathione beta-synthase deficiency 

(homocystinuria) 

Marfans 

& 

VVeill-Marchesani syndrome 

Differential Diagnosis of Drusen: 

AGEING 

submitted by Philip Alexander (source 

Alports Syndrome 

Glomerulonephritis 

Exudate (Hard) 

Inherited (Familial Dominant Drusen) 

North Carolina Dystrophy 

starGardts and fundus flavimaculatus 

Features of posterior scleritis: POST 
SCLER 

Submitted by Jim McHugh (source of 
list: Kanski) 



Proptosis 

Ophthalmoplegia 

Svvelling of disc 

Thickening of sclera (US/CT) & T sign 

(fluid in sub-Tenon's space) 

Subretinal exudates 

Choroidal foLds 

Exudative RD 

Ring choroidal detachment 

There are many systemic conditions that 

have ocular manifestations. See also 

the Uveitis section. 

Features of VVeill-Marchesani 

syndrome: 6 S's 

Submitted by Jim McHugh (source of 

list: Kanski) 

Short 

Stubby fingers 
Stupid 

Spherophakia 
Subluxed lens 
Shallovv AC (?) 



Systemic features of Marfan 
syndrome: MARFANS 

Submitted by Jim McHugh (source: 
Kanski) 

Mitral prolapse 

Aortic dissection 

Regurgitant aortic valve 

Fingers long (arachnodactyly) 

Arm span>height 

Nasal voice (high arched palate) 

Sternal excavation 

Ocular features of Marfan's: CLUMPS 

Submitted by Jim McHugh (source: 
Kanski) 

Cupping (glaucoma) 

Lattice 

Upvvard lens subluxation 

Myopia 

Cornea Plana 

Sclera blue 

Things to remember about Lyme 
Disease: TICK'S CRAP 



10 



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Submitted by Jim McHugh (source: 
Kanski) 

Tick-borne 

Iritis & intermediate uveitis 

Conjunctivitis 

Keratitis (subepithelial, punctate) 

Svvelling of disc & Star at macula 

Cardiac arrythmias (conduction defects) 

Rash (erythema migrans) 

Arthritis 

Palsies 

Suspicious Choroidal Naevi: To Find 
Small Ocular Melanoma 

Submitted by Philip Alexander (source 
of mnemonic: Professor Carol Shields, 
EURetina 2006) 

Thickness >2mm 

Fluid (subretinal) 

Symptoms 

Orange pigment (lipofuscin) 

Margin at optic disc 



Classification of 
Retinoblastoma: ABCDE 

Submitted by Philip Alexander (source 
of mnemonic: Professor Carol Shields, 
EURetina 2006) 

SmAII (<3mm) 

Bigger (>3mm, macular, subretinal fluid) 

Contained Seeds 

Diffuse seeds (>3mm) 

Extensive (>50% globe, opaque media, 

NVI) 

Systemic Features of Sarcoid: 

FILLED BAGEL 

Submitted by Jim McHugh (source of 

list: Kanski) 

Facial nerve palsy 

Infiltrates of lung parenchyma, 

Insufficiency of pituitary 

Lymphadenopathy (esp lung hilae) 

Liver & spleen enlargement 

Elevated ACE & calcium 

Dilated cardiomyopathy 

Bone cysts 

Arthralgia 



Granulomata of skin 
Erythema nodosum 
Lupus pernio 

Features of Behcet's Disease: ORAL 
UPSET 

Submitted by Jim McHugh (source of 
list: Kanski) 

Occlusive periphlebitis 

Retinitis 

Anterior uveitis 

Leakage from retinal vessels 

Ulceration (aphthous/genital) 

Pustules after skin trauma (Pathergy 

test) 

Scratching leaves lines 

(dermatographism) 

Erythema nodosum 

Thrombophlebitis 



Clinical features of Reiter's: 
FUCKING 

Submitted by Jim McHugh (source of 

list: Kanski) 

Plantar Fasciitis 

Urethritis 

Conjunctivitis 

Keratoderma blenorrhagica 

Inflamed joints 

Nail dystrophy 

Gum ulceration 



Ophthalmic features of TB: BCG GP 

Submitted by Jim McHugh (source of 
list: Kanski) 

Busacca & Koeppe nodules on iris 

Choroiditis 

Granulomata in choroid 

Granulomatous uveitis (with mutton fat 

KP's) 

Periphlebitis 



REFRACTIVE INDEX- 8304 

1.38 - cornea 
1.33 - aq humour 
1.40 - lens 
1.33 - vit humour 



11 



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complicated cataract is RIGID 

R- retinal detachment 

I- inflammatry conditions like iridocyclitis, 

hypopyon, choroiditis, endophthalmitis 

G- glaucoma {primary n secondary} 

I- intraoculartumors 

D- degenerative conditions {retnitis 

pigmentosa, retnal dystrophies} 

surgeries: entropion 

Ouote: 

CICATRICIAL ENT: skin n muscle of 
beautiful jia khan 

1- skin n muscle resection 

2- skin, ms n tarsus resection 

3- burrovv's operation 

4- jaesche arif operation 

5- ketssey's operation 



RETINITIS PİGMENTOSA 

Quote: 



systemic ds ass vid retinitis pigmentosa are 

LUCH R 

L- laurence moon biedl synd 

U- usher's synd 

C- cockayne's synd 

H- hallgren's synd 

R- refsum's synd 

some silly ones 

Quote: 



Hm 

ke; 
Ea 



SENILE ENT: BeVViTched 

Quote: ■ 

1- bick's procedure 

2a- vvheeler's operation 

2b- vveiss operation 

3- tucking of inferior lid retactors 

surgeries: ptosis 

Quote: 




FLU FFY 

F- fasanella servat operation 

L- levator resection {blaskovics n 

everbush's} 

F- frontalis sling operation 



Anopsia: quarantic anopsia: 
location of lesion 



Upper: Top: Temporal lesions. 
Lovver: Pits: Parietal lesions. 
Show Details / Rate İt 
— Sung Hoon Kim VVonkang Univ Medical 
school, South Korea 



Cataracts: causes 



ABCDE: 

Aging 

Bang: trauma, other injuries (eg 

infrared) 

Congenital 

Diabetes and other metabolic 

disturbances (eg steroids) 

Eyediseases: glaucoma, uveitis 

Show Details / Rate İt 

— Anthony Chan 



İM INJECTION IS EAZY 

key word İM --> internal hordeolum is in 

meibomiam gland 

EaZy-> external hordeolum is in zeis gland 



PR IS DANGEROUS İN TB 

key word 

PR~> PROTOANOPES cant see RED 
DG~> DEUTROANOPES cant see GREEN 
TB~> TRITOANOPES cant see BLUE 



difference b/w glands of moll n zeis 

mohl means a don's girlfren{a hot gal} who 

evryl looks at n then SVVEATS 

so moll are svveat glands 

and zeis are sebaceous glands 




11 



Optic atrophy causes 



ICING: 

Ischaemia 

Compressed nerve 

Intracranial pressure [raised] 

Neuritis history 

Glaucoma 

Show Details / Rate İt 

— Anonymous Contributor 



Red eve causes 



GO SUCK: 

Glaucoma 

Orbital disease 

Scleritis 

Uveitis 

Conjunctivitis 

Keratitis 

Show Details / Rate İt 

—Anonymous Contributor 



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Dacryocystitis, dacryoadenitis: 
apparatus affected 



Dacryocystitis, dacryadenitis: 

■ Cry, so affects lacrimal gland. 

■ Infection and inflammation, 
respectively. 

Show Details / Rate İt 
— Anonymous Contributor 



Cataracts: causes 



CATARAct: 

Congenital 

Aging 

Toxicity (steroids, ete) 

Accidents 

Radiation 

Abnormal metabolism (diabetes 

mellitus, VVilson's) 

Show Details / Rate İt 

Periorbital cellulitis: etiology 

SIGHT: 

Sinusitis 

Insect Bite 

Globular/ Glandular Spread 

Heme Spread 

Trauma 





Diplopia (uniocular): causes 



ABCD: 

Astigmatism 
Behavioral: psychogenic 
Cataract 
Dislocated lens 
Show Details / Rate İt 
— Anthony Chan 



Corneal stromal dystrophies 



"Marilyn Monroe Gets High in LA": 
Macular: Mucopolysaccharide 
Granular: Hyaline 
Lattice: Amyloid 
Show Details / Rate İt 



Nasopharyngeal cancer: elassic 
symptoms 



NOSE: 

Neck mass 

Obstructed nasal passage 

Serous otitis media externa 

Epistaxis and diseharge 

Show Details / Rate İt 

— Robert O'Connor University College 

Dublin 



Cataracts: differential 



CATARAct: 

Congenital 

Aging 

Toxicity (steroids, ete) 

Accidents 

Radiation 

Abnormal metabolism (DM, VVilsons, 

ete) 






lf u have more mnemonics : share with us at 



http://qroups.yahoo.com/group/medshams/ 



Answer ali questions, no surgical details needed: 

1-What do you understand by the term ciliary injection? 

2-Discuss the signs and symptoms of diseases causing ciliary injection. 

3-How would you investigate a patient suffering from watering of his eye 

(Lacrimation 

and epiphora)? 

4-Comment on the following: 

• Papilloedema. 

• Orbital cellulites. 



• Ocular lime burn. 

5-Describe the clinical features and treatment of diabetic changes in: 

• The lens. 

• The retina. 

6-Enumerate the various methods of examination of the field of vision and 

comment on 

their clinical application, what do you mean by the term positive, negative, 

relative, 

absolute Scotoma? 



1984 



Answer ali questions, no surgical details needed 

1-Draw a sagittal section of the upper lid; discuss the different sections of the 

upper lid. 

2-How would you diagnose and treat a case of senile cataract? 

3-A child 5-year-old presented with a red eye, Enumerate and differentiates the 

possible causes 

4-Describe the possible mechanisms by which blunt trauma to the eye induce rise 

of the 

IOP. 

5-Comment on: 

• Cover test. 

• Asthenopia. 

1985 



Answer ali question, no surgical details needed 

1 -Discuss aetiology, clinical picture and management of corneal hypopyon ulcer. 

2-Describe the aetiology, clinical picture of trachoma. 

3-Give an account on: 

• Chalazion of the lid. 

• Regular astigmatism. 

4-Describe the clinical course and management of retinoblastoma. 
5-What is the management of 1ry acute congestive glaucoma? 



Answer ali Ouestion, no surgical details needed 

1 -Discuss the aetiology, clinical picture, and the possible complications of 

bacterial 

mucopurulent conjunctivitis. 

2-Discuss the clinical picture and treatment of acute iritis. 

3-What are the signs of surgical aphakia? Give an account on treatment. 

4-Comment on the following: 

• Orbital cellulites. 

• Regular astigmatism 



14 



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Answer ali Ouestion, no surgical details needed 
1-Describe the clinical complications of trachoma. 
2-Discuss the importance of the size of the pupil. 
3-What is meant by 2ry glaucoma, discuss its causes? 
4-Comment on the following: 

• Presbyopia. 

• Diabetic retinopathy. 



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1987 



Answer ali question, no surgical details needed 

1-Draw a diagrammatic sagittal section of the upper eyelid. 

2-What are the causes and management of cicatricial entropion of upper lid? 

3-Discuss aetiology, clinical picture and treatment of try hypopyon corneal ulcer. 

4-Discuss clinical picture of the different stages of senile cataract; comment 

brief ly on 



its treatment. 

5) Give a short account on: 

* Panophthalmitis. * Papilloedema. 



1987 



Answer ali question, no surgical details needed 

1-Describe the clinical picture of spring catarrh; Give an account on its treatment. 

2-What are the anatomical and physiological characteristics of the normal pupil? 

3-Explain how may iritis lead to 2ry glaucoma? 

4-What are the commonest causes of bilateral gradual failure of vision in a 

healthy 60 

years patient with emmetropic eyes, Comment on the treatment of one of them? 

5-Give a short account on: 

• Causes of unilateral proptosis. 



15 



• The clinical picture of diabetic retinopathy. 



Answer ali question, no surgical details needed 

1-Describe the various types of entropion and their management. 

2-Describe the clinical stages of senile cataract. 

3-How can affection of the lens cause 2ry glaucoma? 

4-Give an account on the causes, signs, symptoms, complications and treatment 

of 

acute iridocyclitis. 

5-Discuss the causes of Optic atrophy. 

6-How can corneal affection causes defective vision. 



Answer ali question, no surgical details needed 

1-Enumerate the types of allergic conjunctivitis. 

2-How you treat a case of infective conjunctivitis? 

3-What are the common complications of infective conjunctivitis? 

4-Enumerate the causes of ciliary injection. 

5-What are the symptoms and signs of acute iritis? 

6-What are the complications of acute iritis? 

7-High myopic patient developed rapid drop of vision in one eye: 

• What are the possible causes of drop of vision in this patient? 

• Enumerate the types of myopia. 

• Describe the signs seen in the fundus of the other eye. 
8-Enumerate the complications that occur in the eyeball following trauma by a 
tennis 

ball. 

9-What are the complications and treatment of traumatic hyphaemia? 



1990 



Answer ali questions. No surgical details needed. 
1-Discuss causes of ptosis, Mention its treatment. 
2-Pannus: 

• Give the definition of corneal pannus. 

• What are the different causes of pannus? 

• Discuss the types and treatment of the commonest pannus in Egypt. 
3-Discuss causes of errors of refraction. 

4-Give an account on treatment of the irregular astigmatism. 

5-How you proceed to diagnose a case of öpen angle (chronic simple) glaucoma. 

6-What are the factors that affect the prognosis of cases of simple glaucoma? 



16 






f 






1991 



Answer ali question, no surgical details needed 

1-Discuss entropion of the lower lid, Mention its clinical picture and management. 

2-Discuss the corneal manifestations of trachoma, 

3-How can the crystalline lens cause 2ry glaucoma? 

4-Discuss the management of acute congestive glaucoma (closed angle 

glaucoma). 

5-How would you manage a case of myopia, mention the complications of 

progressive 

myopia. 

6-Discuss types of Optic atrophy. 

7-Write short notes on: 

• Supp. Endophthalmitis. 

• Management of lacrimal fistula. 

• Effect of blunt trauma on the iris. 



1992 



Answer ali question, no surgical details needed 

1-Discuss the clinical picture, complications and management of phylectenular 

keratoconjunctivitis. 

2-Discuss the clinical picture and management of lamellar cataract. 

3-Discuss the medical treatment of chronic simple glaucoma (POAG). 

4-Write notes on: 

• Complications of acute anterior Uveitis. 

• Causes and manifestations of chronic dacryocystitis. 
5-Write notes on: 

• CRVO. * Presbyopia. 

- - 17 - - 



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1993 



Answer ali question, no surgical details needed: 

1-Discuss the complications of corneal ulcers. 

2-What are different types of ectropion. Discuss the clinical picture. 

3-Describe the clinical picture and treatment of spring catarrh. 

4-Describe the clinical picture of acute dacryocystitis, Mention differential 

diagnosis. 

5-Discuss the causes of watering of the eye in a newbom. 

6-Write short notes on: 

• Stages of senile cataract. 

• Evaluation of visual acuity in infants and children. 

• Opticatrophy 



1994 



Answer ali question, no surgical details needed: 

1-Draw a section in the lid to illustrate its anatomy. 

2-Explain the different clinical types of ectropion of the lid. Mention management 

of 

each type. 

3-Discuss the causes, clinical picture, and treatment of hypopyon ulcer of the 

cornea, 

what are its complications and their management? 

4-What are the types of traumatic cataract? Explain the clinical picture. 

5-Explain the different methods for the optical correction of aphakia. 

6-Write notes on: 

--18-- 



• Papilloedema. 

• Regular astigmatism. 

• Congenital glaucoma. 

7-Describe the aetiology, clinical picture and differential diagnosis of 
Papilloedema. 



1995 



Answer ali question, no surgical details needed: 

1)Discuss the CL/P & differential diagnosis of trachomatous kerato-conjuctivitis. 

2)Discuss the aetiology & CL/P of congenital cataract. 

3)Discuss the management of unilateral total cataract. 

4)What are the possible effects of a blunt trauma on the ant. Segment of the eye. 

5)How would you treat chemical injuries to the eye. 

6)Discuss the possible complications of progressive myopia. 

7)Describe the aetiology,C/P,& differential diagnosis of Papilloedema 





19 



1996 

Answer ali question, no surgical details needed: 

1)Describe the CL/P of the different types of entropion 7 their ttt. 

2)Discuss the aetiology ,CL/P & complications of hypopyon corneal ulcer ,What is 

the management? 

3)Discuss the management of : 

* Soft cataract. * Buphthalmos. 
4)Write notes on : 

* Presbyopia. * 2ry retinal detachment. 



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1997 



Answer ali question, no surgical details needed: 

1) Discuss symptoms,signs & ttt of an acute attack of closed angle glaucoma. 

2) Discuss the aetiology & CL/P of the different types of congenital cataract. 

3) Explain the possible retinal complications of DM outline ttt. 

4) Write short notes on : 

5) Dendritic corneal ulcer. 

6) Keratoconus. 

7) Complications of progressive myopia. 



1998 



Answer ali question, no surgical details needed: 
1)Describe types & ttt of ectropion. 
2)Discuss the CL/P & management of acute iridocyclitis. 
3)Discuss types, aetiology,& CL/P of congenital cataract. 
4)Write short notes on : 

* Buphthalmos. 

* CRAO. 

* Central manifeststions of trachoma 

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1999 

AN Questions will be answered,No Operative detalies is required: 

LDiscuss Types, Clinical picture & management of congenital cataract. 

2.Discuss eitiology ,clinical picture ,complication &managment. Acute ant. 

Uveitis. 

3-Discuss types, causes,complication& management of corneal opacities. 

4.write short notes: 

l)infected chalazion 

ii)central retinalartery occlusion 

c)Latent sguint 



2000 



Ali Questions will be answered,No Operative detalies is required 

Lgive the eitiology &management of mucoprulant conjuctivites 

2.give the clinical picture of paralyitic squint 

3.describe the field change in öpen angle glaucoma 

4.what is the eitiology &clinical picture of denteric corneal ulcer 

5.complication of progressive myopia 

6.describe the eitiology & clinical picture& ttt of acute optic neuritis 

7.clinical picture of senile cataract 

8.complication of ant. Uveities 

9-ttt of trichiasis 

10.diagnosis of chronic dacryo-cystities 



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June2001 



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1 






1.what is lagophthalmos?give it's cause 

2.what is etiology & cl.picture of veneral keratconjuctivites 

--21-- 



3.give an account on el. Picture of 1ry buphthalmos 

4.give an account on cause of dry eye 

5. discuss cause of ocular headache 

6.discuss management of resistant corneal uleer 

7.discuss visual rehailitation after congential cataract surgery 

8.what are astigmatism & discuss its type 

9.what is the differential diagnosis of painful proptosis 

10. discuss cl.picture of central retinal artery occlussion 



JUNE 2002 



1 -discuss the clinical picture and management of cicatricial enteropion. 

2-discuss etiology, and management of membranous conjunetivitis. 

3-discuss the etiology, clinical picture and complication of corneal uleer with 

hypopyon. 

4-mention the management of acute iridocyclitis and its complications. 

5-how would you proceed to diagnose the primary öpen angle glaucoma. 

6-mention the clinical picture of paralytic squint. 

7-diagnosis of intraocular foreign body. 

8-etiology and management of anisometropia. 

9-fundus picture of central retinal vein ocelusion. 

10-etiology and management of : 

*congenital cataract. 

*infected chalazion 

*central retinal artery ocelusion 

*lat ent sguint 



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September 2002 



1-what are : 

a-symptoms and signs of keratoconus 

b-etiology and clinical picture of optic neuritis 

2-discuss: 



22 



a-causes of complicated cataract. 

b-clinical picture and management of rhegmatogenus retinal detachment. 

3-give an account on: 

a-complication of acute iridocyclitis 

b-types,clinical picture and management of blepharitis 

4-write short notes on: 

a-blunt trauma of crystalline lens 

b-clinical picture and etiology of 3rd nerve paralysis 

5-discuss : 

a-clinical picture, complication of retinitis pigmentosa 

b-clinical picture of chronic dacryocystitis 

6-mention: 

a-clinical picture and management of spring catarrh 

b-clinical stages of malignant intraocular tumors 

7-write notes on: 

a-clinical picture of primary buphthalmos. 

b-clinical picture and management of presbyopia 

June 2003 




1-what arw the complication of ant. Uveitis (25 marks) 
2-discuss clinical picture and management of herpetic keratitis.(25 m) 
3-what are the causes and management of blepharitis.(25 m) 
4-discuss the effect of blunt trauma on crystalline lens (25 m) 

5- what are the causes of secondary glaucoma.(25 m) 

6- give notes on: (15 m) 
* staphyloma 
*keratoconus 
*types of optic atrophy. 

September 2003 

No surgical details are required 

1. Discuss the c/p of Acute Anterior Uveitis 

2. Mention complications of Degenerative Myopia 

3. What is the c/p of Central Retinal Artery Occlusion? 

4. Discuss the ttt of different types of Entropion. 

5. Mention corneal manifestations of Trachoma 

6. Discuss the stages of Senile Cataract 

7. Discuss the visual field changes in Chronic Simple Glaucoma 

8. Mention the clinical picture of Optic Neuritis 

9. What are the causes of Unil. Proptosis 
10.What are the causes of Concomitant Squin 




May 2004 



No surgical details are required (14 marks for each question) 

1. Discuss the management of Congenital Blepharoptosis. 

2. What are the causes of Complicated Cataract? 

3. Discuss the c/p and investigations of Retinoblastoma. 

4. Discuss the pathology of bacterial Corneal Ulcer 

5. What are the field changes in Primary Öpen Angle Glaucoma? 

6. Mention the etiology and c/p of 3rd Nerve Palsy. 



23 



7. Give an account of the Ocular complications of Trachoma. 

8. Discuss the complications of Central Retinal Vein Occlusion 

9. Describe the c/p and complications of Chronic Dacryocystitis. 
10-Describe different ways of ttt of Myopia. 

September 2004 

Answer ali questions, no surgical details needed: 

1. Discuss management of cicatricial ectropion of the lower lid. 

2. Discuss complications of anterior uveitis. 

3.What is the management of congenital cataract? 

4. Discuss the clinical picture of vernal keratoconjunctivitis (spring catarrh). 

5.What is the management of concomitant squint? 

6.Describe the clinical picture of diabetic retinopathy. 

7.What are the clinical picture & investigations of keratoconus? 

8.What are the causes of mydriasis? 

9.Mention the treatment of hypermetropia (hyperopia). 

10.What are the causes of 2ry glaucoma? 

May 2005 



AN questions are to be answered: 

1. Clinical picture of spring catarrh. 

2.Causes of complicated cataract. 

3.Causes of miosis. 

4.Etiology & clinical picture of hypermetropia (hyperopia). 

5.Etiology & clinical picture of central retinal artrey occlusion. 

6.Clinical picture of paralytic squint. 

7.Clinical picture & treatment of trichiasis (no surgical details). 

8.0ccular causes of headache. 

9.Management of acute angle closure glaucoma. 

10-Clinical picture & management of bacterial corneal ulcer. 




September 2005 



ectencular 



1-Give an account on lagophthalmos. 
2.Clinical picture & diagnosis of dry eye. 
3.Clinical picture & differential diagnosis of phlyec 
4. Discuss complications of anterior uveitis. 
5.Management of acute angle closure glaucoma. 
6.Clinical picture & investigation of retinitis pigmentosa. 
7.Clincal picture & diagnosis of retinoblastoma. 
8.Definition, compaints & treatment of anisometropia. 
9.Diagnosis of latent squint. 
10.Causes of true proptosis. 



keratoconjunctivitis. 



May 2006 



1. Discuss causes, clinical picture & complications of lagophthalmos. 



24 



2.Discuss different presentations, differential diagnosis & treatment of corneal 

phlycten. 

3.Write the clinical features & investigations of keratoconus. 

4.Write the definition & types of staphyloma. 

5-Discuss the complications of anterior uveitis. 

6.Discuss the morphological types of congenital or developmental cataract. 

7-Discuss the medical treatment of 1ry öpen angle glaucoma. 

8-Discuss the clinical picture, diagnosis & complications of retinitis pigmentosa. 

9-Discuss the aetiology of hypermetropia. 

"lO.Discuss the clinical picture of paralytic squint. 

September 2006 



LDiscuss types, clinical picture & treatment of ectropion. 

2-Discuss how to treat a case of epiphora. 

3.Give an account on sympathetic ophthalmitis. 

4-Discuss the differential diagnosis of acute congestive glaucoma. 

5.Give an account on the complications of trachoma. 

6.Give an account on the complications of high myopia. 

7-Discuss the differential diagnosis of orbital cellulitis. 

8-Discuss the complications of congenital cataract. 

9-Discuss the clinical picture & treatment of dendritic ulcer 

10-Give an account on diagnosis of latent sguint. 




May 2007 



1-give an account on: complications of trachoma 

2- give an account on: fungal keratitis 

3- give an account on: clinical picture of 1ry öpen angle glaucoma 

4- discuss management of acute iridocyclitis 

5- discuss causes of miosis 

6- discuss the morphological types of congenital or developmental cataract 

7- give an account on:clinical picture of different types of optic atrophy 

8- give an account on: definition and diagnosis of latent squint 

9- discuss the clinical picture and complications of hypermetropia 

10- discuss causes and different diagnosis of sub-conjunctival haemorrhage 



following trauma 



25 



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Curriculum for Undergraduate Students 



ESOPHAGOLOGY 



RHI NOLOGY 



1. Anatomy of the Esophagus. 

2. Diagnosis of the Esophagus Disorders. 

3. Congenital Disorders of the Esophagus. 

4. Trauma to the Esophagus. 

5. I nflammation of the Esophagus. 

6. Neuromuscular Disorders of the 
Esophagus 

7. Neoplasms of the Esophagus. 

PHARYNGOLOGY 

1. Anatomy of the Pharynx. 

2. Functions of the Pharynx. 

3. Symptoms, Signs and I nvestigations of 
Pharyngeal Diseases. 

4. Diseases of the Nasopharynx. 

5. Diseases of the Oropharynx. 

6. Diseases of the Hypopharynx. 

7. Snoring & Sleep Apnea. 



LARYNGOLOGY 






1. Surgical Anatomy of the Larynx. 

2. Functions of the Larynx. 

3. Examination of the Larynx. 

4. Congenital Diseases of the Larynx. 

5. Laryngeal Trauma. 

6. I nflammations of the Larynx.. 

7. Paralysis of the Vocal Folds. 

8. Tumors of the Larynx. 

9. Operative Laryngology. 
lO.Foreign Body Inhalation. 
ll.Phoniatrics. 



1. Anatomy of the Nose & Paranasal 
Sinuses. 

2. Functions of the Nose & 
Paranasal Sinuses. 

3. Diagnosis of Sinonasal Diseases. 

4. Congenital Diseases of the Nose. 

5. Traumatic Conditions of the Nose. 

6. Diseases of the External Nose & 
Nasal Septum. 

. Epistaxis. 
. Allergic Rhinitis. 
9. Vasomotor Rhinitis. 
10. Nasal Polypi. 
11. 1 nflammations of the Nasal 

Cavity. 
12.1 nflammations of the Paranasal 

Sinuses. 
13.Cysts in Relation to the Nose & 

Sinuses. 
14. Tumors of the Nose & Paranasal 

Sinuses. 
15.Headache &Facial Pain. 

OTOLOGY 



Anatomy of the ear. 

Physiology of Hearing and 

Equilibrium. 

Symptoms of Diseases of the Ear 

& Facial Nerve. 

I nvestigations of Diseases of the 

Ear & Audiology. 

Diseases of the External Ear 

Diseases of the Middle Ear. 

Diseases of the Otic Capsule. 

Diseases of the I nner Ear. 

Disorders of the Vestibulocochlear 

Nerve. 






27 



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1 . Give an account on Tuning fork tests 75 

2. Give an account: the causes & clinical picture of acute otitis media in infants 76 

3. A 3 years old child complaining of RT mucopurulent otorrhea for the last 2 years. He 
suddenly became feverish & this was associated with diminution of the ear discharge. 
What is the diagnosis & differential diagnosis? 77 

4. A middle-aged female was having dysphagia of 10 years duration, together with 
rehuritation of regurge free of acid. On examination her condition appeared relatively 
good. What is you diagnosis & differential diagnosis 78 

5. A patient presented with ear ache, what are the sources of pain & how would reach 
the diagnosis 78 

6. Discuss earache 80 

A male Pt 25 year has been complaining from a discharging RT ear for the last 7 years. 
The discharge was offensive & blood 

7. stained. 5 weeks he started to complain from headache which gradually increased & 
was associated with vomiting. Now the pt is drowsy he is 37.50C & C.S.F. on 
examining the discharge was seen coming from a perforation in the attic. 

what is the most probable diag.? 

I) Explain why did you choose this particular diag. 

II) How would you proceed to confirm your diag.? 

III) Comment on ear condition 80 

8. Give an account on symptoms & signs of acute mastoiditis 81 ,82 

9. Give an account on manifestations of unresolved acute supportive O.M 

10. Give an account etiology, symptoms, signs & ttt of acute supportive O.M. in a 
child 3 years old 82, 90 

11. An adult Pt having a Rt mucopurulent ear discharge for more than 10 years, 
suddenly he became dizzy with sever vomiting sever it us & total deafness of the 
Rt ear. Few days later he started to feelsever headache & some stiffness of neck 
back muscles. 

COMMENT ON: 

I) Diagnosis of the original condition. 

II) What is the cause of sudden dizziness & hearing loss? 

III) What happened later on? 

IV) Management of the case 83 

12. A 6 old child developed sever pain in both ears together with a rise to temp. 39°C. 
following an attack of acute rhinitis. The child received medical ttt which lead to 
drop of temp & subsidence of pain; so the physician stopped the ttt. However, the 
mother noticed that her child did not respond except when she raised her voice 
for the last 2 weeks after they 1 ry condition 
COMMENT ON: 

I) Diagnosis of the 1 ry condition. 

II) Causes of the residual trouble & the appearance of the T.M. 

III) How to avoid such trouble. 

IV) How would you treat the child now 84 

13. Give an account on the symptoms, signs, investigations & ttt of case of chronic 

suppurative O.M. 

14. How do you differentiate between upper & lower motor neuron facial n paralysis. 
Enumerate the causes of lower motor neuron 7 th n paralysis & discuss the ttt of the 
commonest cause 87 

15. A 3 years old child was presented to an E.N.T. specialist because of inability to 
close the RT eye & deviation of the angle of the mouth to the left side on crying of 2 
days duration. His mother reported that he had severe pain in the Rt ear 5 days 
before which improved on antibiotic ttt. 

I. What is the possible diagnosis of this case? (Both original pathology & 
complications). 

- - 28 - - 



II. What are the possible ontological findings? 

III. Discuss the management of this case 88 

16. Give an account on ontogenetic meningitis89 

17. A male pt 47-year-old presented to the etiologist because of pain in the Lt Ear of 2 
days duration, pain was throbbing in character & increased in severity during 
mastication. The pt gave a history of 2 similar attacks in the last 6 months. On 
examination movements of the İt auricle were painful & a circumscribed reddish swelling 
was found arising from the outer portion of the posterior meatal wall. The retroauricular 
salcus tender swelling. 

Tuning fork test revealed + ve Rinne's test on both sides & VVeber's test was centralized. 

I) Mention the moat likely diagnosis. Give reasons. 

II) Mention one important D. D & state the differentiating points. 

III) Mention 2 possible causes for the recurrence of these swellings. 

IV) Outline the ttt of this pt 90 

18. Discuss the causes, symptoms, signs & ttt acute O.M. in children 91 

19. List 3 common causes of referred otalgia. Name the responsible nerve in each 

20. A male Pt 25 years old asked medical advice because of intense earache 
together with discharge from the RT ear. The ear discharge was scanty foul 
smelling & of 5 years duration. Headache started 6 weeks ago, increased in the last 
2, & became associated with vomiting, vertigo & blurring of vision. On examination, 
the pt was found not alert, having abnormal gait with tendency to fail to the Rt 

side. His temperature was 36°C the pulse was 62/min. Examination of the ears 
revealed Rt attic perforation & tuning fork testing showed Rt C.H.L. 

A) State the most probable diagnosis of the case. Give reason to 
substantiate your diagnosis. 

B) List the investigations you order to prove your diagnosis. Comment on 
the possible findings. 

1 m 

C) Explain the cause of the following findings: 

1. Vertigo. 2. Blurring of vision. 

3.Vomiting. 4. Temp. 36°C. 

D) Describe the ttt of this pt. 









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1 . Give an account on general causes of epistaxis 



75, 76, 83 



29 



2. Management of a case of epistaxis 78, 80, 83, 84, 89, 93 

3. TTT of scleroma 78 

4. Sequale of long standing nasal obstruction 78 

5. A male pt. 49 years old complains of enlargement of the upper deep cervical L.N. 
on both sides of 6 month duration (but 1st on the Rt side then the Lt) the Pt gave 
the history of decrease of hearing in the left ear, nasal obstruction, recurrent 
epistaxis & nasal intonation. 

I. What is the most probable diagnosis? 

II. Why did you choose this particular diagnosis? 

III. How would you proceed to confirm your diagnosis? 

IV. Outline the management of the case 81 

6. A 25 years old pt had been complaining of severe acute rhinitis on the 5th day he 
started to get severe headache mild fever & marked pain över forehead. The pt did 
not receive any ttt & on the 10 th day he started to get repeated rigors & become 
severely ili. On examining the pt the following signs were detected: 

o A large furuncle was present in the RT Nasal vestibule. 

o Marked edema of both lids. 

o Chemosis of the conj. 

o Forward proptosis of the RT eye ball. 

I) What did the Pt developed on the 5 th day & what other signs & symptoms do you 

expect at this stage. 

II) What şort of complications the pt developed on the ı th day & that other signs 
& symptoms do you expect at this stage? 

III) Explain how did this last complications occur (pathogenesis) 82 

7. How would you treat a case of acute sinusitis? 86 

8. A 5 years old boy was referred to an E.N.T. specialist bec of mouth breathing & 
impairment of hearing of 2 years duration. His mother reported that her child has 
almost constant mucoid nasal discharge sometimes changes to mucopurulent & he 
snores during sleep Examination of the ear shows both drums intact. 

I) What is the most likely diag.? 

II) Explain: 
o Hearing loss 
o Changing of the character of the nasal discharge. 

III) Describe the other expected signs. 

IV) What are the investigations you advise to confirm your diag.? 

V) Discuss the ttt 87 

9. Discuss the nasal polyp 91 

10. Discuss the main lines of ttt for frontal sinusitis 



Give an account on laryngeal obstruction İn young children 75 

Give short account about causes & ttt of reactionary hg after tonsillectomy 

76 
How can you differentiate between dyspnea of laryngeal origin from other 
causes of dyspnea 77 

40 years old pt male urgent tracheostomy to by pass. Later he becomes 
dyspnic again. What are the possible causes 77 

Discuss causes, symptoms, signs & management of acute laryngeal obst in 
children (no operative details required) 78 

Give a short note about: 
i. Complications of tracheostomy. 

ii. Ctuinsy 80 

Give short notes about complications of acute tonsillitis 81 

A 3 Years old male Pt was referred to a pediatrician bec of recurring attacks of 
cough together with expectoration & pyrexia improved on receiving ttt of 3 
weeks duration. The previous attack prescribed by his family doctor but the 
symptoms recurred on cessation of ttt. İn the last attack, the child did not 

- - 30 - - 



child 3 years old 82 
throat of sudden onset 



show any improvement with the usual ttt. Clinical examination by the pedant, 
revealed a feverish 38 C & dyspnic child. Auscultation of the chest showed 
diminished air entry together with a localized wheeze on the lower lobe of the 
Rt lung. 

I) What is the most probable underlying cause of the recurrent attacks of 

chest trouble? 

II) What other symptoms & signs would you look for in this case? 

III) Why in you opinion is the cause of lack of response of 
the last attack to ttt. 

IV) What investigations would you order? 
V)Comment on the probable findings. 

9. Give an account on management of laryngitis in 

10. A male Pt 23 year complained from pain in the 
together with difficulty in swallowing & high fever. 5 days later, dysphasia became 
very severe; the pain became localized to the Lt side of the throat & acquired a 
throbbing character. The pt had excessive salivation & Lt ear ache. On 
examination, the pt had marked difficulty to öpen his month & a tender swelling 
below the angle of the mandible could be felt. 

I) What is the most probable diag.? 

II) What are the other signs expected in this case 

III) Flow would you explaining the following findings: 
o The Lt Ear aches. 
o The difficulty in swallowing. 
o The tender swelling below the angle of the mandible. 

IV) Mention one possible common complication. 

V) Outline the ttt of the case 83/82 

11. A year old Pt was referred to an E.N.T SPECIALIST because of cough, 
difficulty of respiration & temp of 39.5°C of little hrs duration & medical ttt 6 hrs 
later the Dr decided an immediate tracheotomy. After the operation the child 
was relieved from dyspnea for 24 hrs when he became dyspnic again. The Dr. 
made minör procedure, which was necessary to relieve the child from the 
difficulty of breathing. Few days later, the tracheostomy tube was removed & 
the child was discharged from the hospital. 

I. Why did the Dr. advise admission of the child to the hospital? 

II. List the observations observed tracheotomy. 

III. Why did the Dr. decided to do tracheotomy. 

IV. Mention the causes of recurrence of dyspnea & how did the Dr. manage it. 

V. What are the measures which can be done before removal of the 
tracheotomy tube 86 



12. Signs & symptoms of laryngeal obst 83, 87, 91 

13. A female Pt 40 year old began to experience difficulty in swallowing for the last 

3 years. This difficulty was to ali kinds of food & the condition showed 
variation in the degree of dysphagia & was associated with the sensation of 
the root of the neck. For the last 2 months, she started to develop rapidly 
progressive difficulty in swallowing even to fluids together with a change in 
her voice. Recently, she noticed a swelling on the RT side of the neck. 

I) How would you examine this case to reach a diag.? 

II) What are the possible clinical findings in this Pt.? 

III) What investigation would you advise to confirm our diag.? 

IV) What is the most likely diag of this Pt? 86 

14. Discuss briefly causes of stridor of sudden onset in children. 88 

15. A 5 years old child underwent adenotonsillectomy operation. On the discharge 
from the recovery room, the child was conscious; BI.P. 110/80, Pulse 100/mm 
& the respiratory rate 16/mm. 4 hrs later, the nurse reported the resident that 
the Pulse became 140/mm, BI.P 100/70 & the child vomited 50 mi blood. 



31 



I) Name the complication, which occurred in this case. Mention the other 
symptoms & signs of such complication. 

II) What are the possible sites of this complication? 

III) How to guard against this complication. 

IV) Describe the symptoms. 

Discuss the symptoms, signs & lit of vocal cord carcinoma 90 
Define stridor, List the commonest 3 causes m young children & describe the 
management 91 

Signs of acute laryngeal obst 92 

Give short account on stridor in children 93 

Ulceromembraneous inflammation of the fauces of young age comment 
on the diag., D.D. & ttt of the most serious of this inflammation 
79 

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THE OESOPHAGEAL DISORDERS 



I) What are the signs of esophageal disorders? 

II) Radiological findings in cases of: Cancer esophagus. 

III) Achalisia. 

IV) Benign stricture. 77 

A middle aged female was having dysphagia of 10 years duration together with 
regurgitation of regurge free of acid. On examination, her condition appeared 
relatively good. 

I) What is your diagnosis & differential diagnosis? 

II) How to investigate & describe the radiological appearance? 78 
Radiological pictures of the esophageal causes of dysphagia 78 

Give an account of the symptoms, signs & differential diagnosis of achalasia 

of the esophagus 87 

Define dysphagia. Discuss the investigations & possible findings of common 

causes of dysphagia of esophageal origin 88 

Give short account on Achalasia of the cardia 93 



32 



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ENT 



N.B these questions are only for training. in the exam you may find Totally different 


questions 


1)tympanoplasty is an operation 




d)blood transfusion 


aimed at: a)correction of hearing in 






porceptive deafness 






b)eradication of infection & 




correction of hearing 




7)referred otalgia may be due to the 


c)drainage of mastoid abcess 


m 


following except: 


d)correction of hearing in 


a)acute suppurative otitis media 


otosclerosis 


b)quinsy 


cjdental infection 


2)surgical emphysema after 




d)maxillary sinusitis 


trachestomy is corrected by: 






a)taking more stitches of the wound 




8)a 3 years old boy complained of 


b)cold compresses 




suuden acute respiratory distress, 


c)widening of the wound by removal 




with spasmodic cough, cyanosis & 


of some stitches 




acting accessory respiratory muscles 


d)antihistaminic intake 




is most probably due to : a)acute 
follicular tonsillitis 


3)commonest cause of septal 




b)foreign body inhalation 


perforation is: a)trauma 




cjadenoid hypertrophy 


b)syphilis 




d)vocal cord nodule 


cjlupus 






d)blood disease 




9)proptosis may be due to the 
following except: 


4)stapedectomy is the operation of 




a)frontoethmoidecele 


choice for: 




b)osteomata of the frontoethmoid 


a)otosclerosis 




cjantrochoanal polyp 


b)bell's palsy 


d)nasopharyngeal fibroma 


cjmeniere's disease 




d)cholesteatoma 


10)the most serious complication 






after tonsillectomy: 


5)saddle nose may be due to the 




a)respiratory obstruction 


following except: a)overresection of 




b)reactionary haemorrhage 


septal cartilage 




cjincomplete removal 


b)nasal trauma 




d)infection 


cjseptal abcess 






d)rhinosceleroma 




11)otoscopic manifestation of 
chronic secretory otitis media may 


6)the best treatment of mild epistaxis 




include the following except: 


from little s area is: a)anterior nasal 




a)perforation at pars flaceida 


pack 




b)transverse handle of malleous 


b)cautery of the bleeding point 
cjposterior nasal pack 




cjabsent cone of light 







U 1 


iUaJl *\£\ 


d)air bubbles behind the tympanic 




a)surgical correction of deviated 


membrane 




septum above 17 years 
b)surgical correction of deviated 


12)tonsillectomy is absolutely 




septum below 17 years 


contraindicated in : 




c) closed reduction of fractured 


a)chronic tonsillitis 




septum by ash's forceps 


b)quinsy 






cjhaemophilia 






d)below f ive years 




19)a 20 years old man c/o fever & 
increasing sore throat with drippling 


13)a newly born infant with 




of saliva &trismus for only 2 days on 


respiratory distress & different 




examination( the right tonsil pushed 


feeding is more likely to be due to: 




medially & forward ) no response to 


a)laryngeal web at the anterior half of 




antibiotics ..rapid relief can be 


vocal cords 




obtained by : a)short course of 


b)bilateral posterior choanal atresia 




radiotherapy 


cjcongenital subglottic stenosis 




b)assurance & rest 


d)congenital meatal atresia 




cjantidephtheric serum 
d)incision & drainage 


14)unilateral offensive blood tinged 






purulent rhinorrhea in a 3 years old is 




20)the most common cause of 


more likely due to: a)rhinosceleroma 




conductive deafness is: 


b)lupus 




a)otosclerosis 


cjforeign body 




b)secretory otitis media 


d)adenoid 




cjcongenital ossicular fixation 
d)collection of wax 


15)the following are manifestations of 






meinere's disease except : 




21)anosmia may be caused by : 


a)vertigo 




a)peripheral neuritis 


b)posterior reservoir sign 




b)nasal obstruction 


cjsensory hearing loss 




cjatrophic rhinitis 


d)tinnitus 




d)all of the above 


16)examination of the chest is more 




22)posterior nasal pack may be used 


important in : 




in : 


a)f ixed right vocal cord 




a)nasopharyngeal carcinoma 


b)f ixed left vocal cord 




b)epistaxis from little's area 


cjsinger's nodules 




c)CSF rhinorrhea 


d)laryngemalacia 


4 


d)post_ adenoidectomy bleeding 


17)manifestations of otogenic facial 




23)ottitic barotraumas is 


nerve paralysis may include the 




charactarised by: 


following except: a)deviation of the 




a)attic perforation 


mouth to the same side of lesion 




b)middle ear effusion 


b)inability to show the teeth on 




cjmucopurulant discharge 


vvhistle 




d)central drum perforation 


c) inability to close the eye 






d)inability to raise the eyebrow 




24)otosclerosis mean : 
a)congenital fixation of incus 


18)conservative septoplasty is: 




b)f ixation of stapes by f ibrous tissue 
cjossicular disruption 







34 



U 1 


iüaîl 31^1 


d)none of the above 




32)the medial wall of the middle ear 

shows ali the following anatomical 

features except: a)eustichian tube 

orifice 

b)horizontal part of facial nerve 


25)all of the followings are absoulute 




cjpromontory 


contraindications for tonsillectomy 




d)oval & round windows 


except: a)rheumatic fever 






b)heamophilia 




33)the most common cause for 


cjadvanced renal disease 




posterior septal perforation is: a)TB 
b)syphilis 


26)unilateral clear watery nasal 




cjleprosy 


discharge reducing fehling's solution 




d)scleroma 


is suggestive of: a)CSF rhinirrhea 






b)allergic rhinitis 




34)moure's sign is: 


cjviral rhinitis 


m 


a)presence of laryngeal click 


d)nasal dipheteria 


b)absence of laryngeal click 






c)external neck swelling 


27)the most common cause of 




d)internal pharyngeal swelling 


oroantral fistula is: a)acute sinusitis 






b)car accident 




35)sridor is characteristic feature of 


cjdental extraction of upper second 




the following diseases except: 


premolar tooth 




a)laryngeal dipheteria 


d)radical antrum operation 




b)angioneurtic edema 
cjadenoid hypertrophy 


28)ear wash is indicated in the 




d)bilateral abductor vocal cord 


following conditions except: 




paralysis 


a)wax 






b)otomycosis 




36)laryngeomalicia is a disease due 


cjimpacted F.B in the ear 




to: 


d)caloric test 




a)voice abuse 
b)soft larynx 


29)post-tonsillectomy otalgia is 




cjvocal cord nodule 


mediated through: 




d)acute laryngitis 


a)vagus nerve 






b)glossolaryngeal nerve 




37)achalasia of the cardia is 


cjtrigeminal nerve 




charactarised by the followings 


d)second & third cervical nerve 




except: 

a)dysphagia is more marked for 


30)nasopharyngeal carcinoma is 




solids thanfluids 


managed by: 




b)dysphagia is more marked for fluid 


a)surgical resection 




than solids 


b)surgical resection followed by 




c)treated by cardiotomy 


radiotherapy 




d)regurgition of undigested food 


c)radiotherapy 




38)subglottic stenosis may be caused 


31)trotter's triad include the 




by ali the followings except: a) 


followings except: a)otalgia 




laryngeoscleroma b) high 


b)epistaxis 




trachestomy 


cjdeafness 




c)post traumatic d)unilateral 


d)deviation of the septum 




recurrent laryngeal N paralysis 



35 



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iUaJl *\£\ 


39)quinsy is due to: a)blood disease 






b)peritonsillar infection 




45)the commenst nasal polyps are: 


cjpharyngoscleroma 




a)ethmoidal polyp 


d)retropharyngeal suupuration 




b)antrochoanal polyps 
cjbleeding polyp 


40)retracted tympanic membrane is 




d)inverted papilloma 


characterized by the following 






except: a)prominent lateral process 




46)ludwig's angina is manifested by: 


of malleus 




a)unilateral submandibular swellings 


b)fragmentation of cone of light 




b)parotid abcess 


cjhyper mobility of tympanic 




cjparapharyngeal abcess 


membrane 




d)sublingual & submental cellulites 


d)accentuation of malleolar folds 




47)forign body nose in a child is 


41)the following symptoms are true 




better extracted: 


of primary atrophic rhinitis except: 




a)under local anaethesia 


a)bad odour felt by the patient 




b)under spinal anaethesia 


b) bad odour felt by others 




c)without anaeathesia 


c)epistaxis 


d)under general anaethesia 


d)sense of nasal obstruction 




48)the following are possible 


42)sever headache, vomiting, 




complications of ear wash except: 


dysphagia ,&visual field defects in a 




a)perforation of the tympanic 


patien with cholesteatoma indicate: 




membrane 


a)secretory otitis media 




b)paralysis of facial nerve 


b)otogenic facial paralysis 




cjcaloric reaction 


cjdistant metastasis 




d)syncope 


d)temporal lobe abcess 




49)suppurative labyrinthitis may 


43)unilateral malignant tumor of the 




complicate: 


vocal cord with subglottis ectension 






& lymph node metastasis is best 




a)salicylate toxicity 


treated by: a)unilateral cordectomy 




b)streptomycin toxicity 


b)total laryngectomy with neck 




cjcholesteatoma 


dissection 




d)otomycosis 


c)cheomotherapy 






d)tracheostomy only 


50)the followings are common 






symptoms of nasopharyngeaol 


44)the commenst presentation of 




carcinoma except: a)nasal 


laryngeascleroma is: a)vocal cord 




obstruction 


paralysis 




b)cranial nerve paralysis 


b)stridor & hoarsness 




cjrecurrent sever epistaxis 


cjpain & night sweating 
d)metastatic lymph node 




d)a mass in the neck 






answers 



1) b 2) c 3) a 4) a 5) d 6) b 7) a 8) b 9) c 10) a 11) a 12) c 13) b 14) c 15) b 16) b 17) a 
18) b 19) d 20) d 21) c 22) d 23) b 24) b 25) a 26) a27) c28)c29) b30) c31) b32) 
a33)b34) b35) c 36) b37) a38) d39) b40) c41) a42) d43) b44) b45) a46) d47) d48) 
b49) c50) c 



36 



j^U\ }\£\ 



1-The following are anatomic 




e- both 1 and 2 


structures of the auricle except : 




f- both 1 and 3 


a- Helix 






b-Tragus 




6-The Eustachian tube is opened by 


c-Concha 




contraction of : 


d-Antrum 




a- tensor tympani muscle 


( The antrum is the largest air cells of 




b-levator palati muscle 


the mastoid bone ) 




c-tensor palati muscle 
d-Salpingopharyngeus muscle 


2-The auriculo temporal nerve 






a-supplies the skin of the upper 2/3 of 




7-The sensory end-organ of the 


the lateral surface of the auricle 




semicircular canal is : 


b- is a branch of maxillary nerve 




a- the organ of Corti 


c- supplies the middle ear mucosa 




b- the macula 


through the tympanic plexus 




c- the crista 


d- non of the above 


■^ 


d- non of the above 


-The auriculo-temporal nerve is a 




-The organ of Corti is the sensory 


branch of mandibular division of the 




end organ of hearing in the cochlea 


trigeminal nerve 




-The macula is the sensory end organ 


- The middle ear mucosa is supplied 




in the utricle and saccule 


by the tympanic branch of 




8-Auricular hematoma 


Glosspharyngeal nerve called 




a- may be complicated by otitis 


Jacobson nerve 




externa 

b- cauli ear is one of its 


3-The lobule of the ear has its 




complications 


sensory innervation from: 




c- evacuation of the extra-vasated 


a-great auricular nerve 




blood is not essential 


b- auriculotemporal nerve 




d-all of the above 


c-arnold branch of vagus 




-Auricular hematoma may be 


d- facial nerve 




complicated by perichondritis and 
cauli ear 


4-The tympanic membrane is divided 




evacuation of the extra-vasated blood 


into: 




is essential to avoid complications 


a- Two equal parts called pars tensa 






and pars f laccida 




9-lt is better to avoid ear wash for 


b- A majör upper part called pars 




removal of : 


flaccida and a small lower part called 




a- wax 


pars tensa 




b- animate foreign body 


c-A small upper part called pars 




c- impacted vegetable foreign body 


flaccida and a majör lower part called 




d- non of the above 


pars tensa 




- Vegetable FB will swell if ear wash 


d- non of the above 




fails to get it out which will cause 
more impaction 


5-The bulge seen on the medial wall 






of the middle ear is : 




10-lt is better to avoid ear wash for 


a- known as the promontory 




removal of : 


b- formed by the bony semicirculr 




a- wax 


canal 




b- animate foreign body 


c-is formed by the basal turn of the 




c-calculator battery 


bony cochlea 
d-all of the above 




d- non of the above 







37 



U 1 


iüaîl ji^ı 


-Don't wash if the FB is a calculator 




a- Rupture of the tympanic membrane 


battery as this may lead to leak of 




b- Ossicular disruption 


acid and chemical burn of the skin 




c- Non of the above 
d- Both 1 and 2 


11 -The causative organism in ear 




17-Longtudinal temporal bone 


fruncle is : 




fracture : 


a- proteus 




a- is less common than the 


b- Pseudomonas 




transverse type 


c- staph. Aeureus 




b- is usually associated with sensori- 


d- E coli 




neural hearing loss 

c- facial nerve paralysis is a common 


12-The causative organism in 




association with this type 


malignant otitis externa : 




d- non of the above 


a- proteus 






b-Pseudomonas 


m 


18-The following organisms are 


c-staph. Aeureus 


involved in acute otitis media except 


d- morexella catarrhalis 




a- streptococcus pneumonia 




b-hemophilus influenza 


13-Malignant otitis externa is : 




c-Pseudomonas aeroginosa 


a- a truly malignant disease eroding 




d-morexella cararrhalis 


the external canal 






b- is most commonly seen in elderly 




19-AII of the following are diagnostic 


uncontrolled diabetics 




of tympanic membrane retraction 


c- staphylococcus aureus is the 




except 


causative organism 




a- fore-shortened handle of malleus 


d- non of the above 




b- prominent lateral process of 
malleus 


14-ln the adult, the Eustachian tube is 




c- Schwartz sign 


approximately the follovving lehgth : 




d- distorted cone of light 


a- 30 mm 




-Schwartz sign is a flamingo red tinge 


b- 20 mm 




of the tympanic membrane due to 


c- 36 mm 




increased vascularity of the 


d- 45 mm 




promontory and indicates active 
otosclerosis 


15-ln Gradenigo syndrome diplopia is 






due to inflammation of the following 




20-Throbbing and severe earach is 


cranial nerve : 




present in the following stage of 


a- IV nerve 


)i 


acute otitis media : 


b- V nerve 


a- stage of salpingitis 


c- III Nerve 


b- stage of catarrhal otitis media 


d- VI nerve 




c- stage of suppurative otitis media 


-This syndrome is charecterized by: 




d- stage of tympanic membrane 


1- otorrhoea 




perforation 


2-facial pain due to iritation of V 






cranial nerve 




21 -The tympanic membrane 


3-diplopia and squint due to iritation 




perforation in acute otitis media is 


of VI cranial nerve in Dorello canal 




a- central in the pars tensa 
b- marginal in the pars tensa 


16-Conductive deafness in 




c- small in the pars flaccida 


longtudinal temporal bone fracture 




d- non of the above 


may be due to: 







38 



j^U\ }\£\ 



22-Type c tympanogram is consistent 






with : 




27-The commonest cause of 


a- secretory otitis media 




conductive deafness in children is: 


b- otosclerosis 




a- wax 


c- Eustachian tube dysfunction 




b-secretory otitis media 


d- otosclerosis 




c-otomycosis 


-İn Type C there is Normal 




d- otosclerosis 


compliance but the peak of the 






tympanogram is at the negative side 




28-The commonest cause of 


so it is consistent with ET 




conductive deafness in adults is: 


dysfunction in which there is 




a- wax 


negative pressure in the middle ear 




b-secretory otitis media 
c-otomycosis 


23-By central drum perforation we 




d- otosclerosis 


meçin . 

a- a perforation at the central part of 




29-ln a patient suffering from 


the drum 




purulent otorrhoea and attic 


b- a perforation in the pars tensa 




perforation : 


which is surrounded by a rim of 




a- treatment is essentially surgical 


tympanic membrane 




b- medical treatment and follow up is 


c a perforation of the pars f laccida 




sufficient 


d- a perforation in the pars tensa 




c- myringoplasty is the only needed 


which is not surrounded by a rim of 




treatment 


tympanic membrane 




d- non of the above 

-The presence of foul odour 


24-AII of the following may be seen in 




otorrhoea and attic perforation is 


the tubotympanic type of chronic 




diagnostic of cholesteatoma. 


suppurative otitis media except 




Treatment of this case is essentially 


a- mucopurulent otorrhoea 




surgical by mastoidectomy operation 


b- central tympanic membrane 




( radical or modified radical) 


perforation 






c- marginal tympanic membrane 




30-ln a 45 years old female patient 


perforation 




presenting with pulsating tinnitus 


d- profuse otorrhoea 




and red mass behind the drum, ali of 
the following are true except : 


25-Cholesteatoma is characterized by 




a- glomus tumour is a possible 


a- continuous mucopurulent ear 




diagnosis 


discharge 




b-more assessment is needed by CT 


b-A foul smelling ear discharge 




scan or MRI 


c- A central tympanic membrane 




c- MRI angiography confirm the 


perforation 




diagnosis 


d- non of the above 




d-biopsy is essential to verify the 
pathological nature 


26-A child with retraced drum and 




-Biopsy is contraindicated as it will 


conductive deafness after inadequate 




lead to profuse bleeding 


treatment of acute suppurative otitis 






media is suffering from : 




31-Bezold abscess is a collection of 


a-chronic tubotympanic otitis media 




pus : 


b-chronic atticoantral otitis media 




a- above and in front of the auricle 


c- otitis media with effusion 




b-behind the auricle 


d- ali of the above 




c-in the upper part of the neck deep 


e-non of the above 




to the sternomastoid 



39 



U 1 


iüaîl ji^ı 


d- in the peritonsillar space 




c-injury of the jagular bulb 
d- residual perforation 


32-During ear examination the 






reservoir sign is diagnostic of: 




38-ln myringotomy operation the 


a- acute otitis media 




posterosuperior quadrant of the 


b- mastoiditis 




tympanic membrane must be avoided 


c- petrositis 




: 


d- cholesteatoma 




a- to avoid injury of dehiscent jagular 

bulb 

b- to avoid injury of the ossicles 


33-An early and diagnostic sign of 




mastoiditis is : 




c- non of the above 


a- reservoir sign 




d- both 1 & 2 


b-sagging of the posterosuperior part 






of the bony canal 




39-The combination of unilateral 


c-perforated tympanic membrane 




otorrhoea, severe facial pain and 


d- postauricular mastoid abscess 




diplopia is known as : 


-Sagging means bulging downwards 




a- Piere Robin syndrome 


of the posterosuperior part of the 




b- Gradenigo's syndrome 


bony external canal and is due to 




c- Kartagner syndrome 


periostitis of the bone overlying the 




d- Ramsay Hunt sundrome 


mastoid antrum. İt is an early and 






diagnostic sign of mastoiditis 




40-A child with an attic drum 
perforation who developed nausea, 


34-Vertigo and nystagmus induced 




projrctile vomiting and fever of 40 


by pressure on the tragus is 




degree is suspicious to have got : 


diagnostic of : 




a- otogenic meningitis 


a- serous labyrinthitis 




b- otogenic labyrinthitis 


b- circumscribed per- labyrintserous 




c- petrositis 


c suppurative labyrinthitishitis 




d- mastoiditis 


d ali of the above 




41 -The first line of treatment in a 


35-ln a case of cholesteatoma, sever 




child who develops lower motor 


spontaneous vertigo with Nausea and 




neurone facial paralysis after acute 


vomiting is suspicious of 




otitis media is : 


a- circumscribed peri-labyrinthitis 




a- antibiotics and corticosteroids 


b- diffuse serous labyrinthitis 




b- decompression of facial nerve 


c- extradural abscess 




c- exploration of facial nerve 


d- petrositis 


d- myringotomy 


36-ln a patient having acute 


m 


42-lntermittent fever with rigors and 


suppurative otitis media with bulging 




headach in a patient with 


drum, myringotomy is benificial to 




cholesteatma may be due to : 


a-drain the middle ear 




a-otogenic meningitis 


b- avoid rupture of the tympanic 




b-otogenic brain abscess 


membrane 




c- lateral sinüs thrombophlebitis 


c-avoid complications 




d-extradural abscess 


d-all of the above 






37-The most common complication of 






myringotomy operation is 




43-A positive Kernig sign means 


a- injury of facial nerve 




a-reflex flexion of the hips and knees 


b-dislocation of the incus 




when the neck is flexed 



40 



j^U\ }\£\ 



b- inability to extend the knee 




c- present with vertigo 


completely when the hip is flexed on 




d- present with pulsating 


the abdomen 




discharge,hearing loss and tinnitus 


c- inability to do rapid ulternating 






movement 




49-The type of hearing loss in 


d- non of the above 




otosclerosis may be 
a- conductive 


44-A positive Brudzniski sign means 




b- sensorineural 


a-reflex flexion of the hips and knees 




c-mixed 


when the neck is flexed 




d-all of the above 


b- inability to extend the knee 






completely when the hip is flexed on 




-İn stapedial otosclerosis hearing 


the abdomen 




loss is conductive 


c- inability to do rapid ulternating 




-İn cochlear type the hearing loss is 


movement 




sensorineural 


d- non of the above 


■fe 


-İn combined otosclerosis the 
hearing loss is mixed 


45-A persistent profuse ear discharge 






after acute otitis media is 






a- cholesteatoma 




50-The commonest cause of bilateral 


b- secretory otitis media 




sensorineural hearing loss in elderly 


c-mastoiditis 




individuals is 


d- diffuse otitis externa 




a- cochlear otosclerosis 


-in mastoiditis there is profuse 




b- presbyacusis 


mucopurulent or purulent otorrhoea 




c- diabetes milltus 


which recurs rapidly after remova ( a 




d- ototoxicity 


diagnostic sign called reservoir sign) 




51 -A 30 years old patient with 
recurrent attacks of vertigo, hearing 


46-ln otitic barotrauma, the following 




loss and tinnitus associated with 


statements are correct except: 




nausea and vomiting has 


a-occurs during airplane ascent 




a- benign paroxysmal positional 


b- occurs during airplane rapid 




vertigo 


descent 




b-vestibular neuronitis 


c- can cause rupture of the tympanic 




c-Meniere's disease 


membrane 




d-acoustic neuroma] 


d- occurs during diving 


^ 


explanation 


47-The commonest cause of vertigo 




1- İn benign paroxysmal positional 


is 




vertigo there is recurrent attacks of 


a- meniere's disease 




vertigo for seconds which occurs 


b-labyrinthitis 




when the patient assumes certain 


c-benign paroxysmal positional 




head position 


vertigo 




2- in vestibular neuronitis there is 


d-ototoxicity 




sudden severe vertigo for dayes but 
bo hearing loss 


48-Most cases of extradural abscess 




3- in Meniere's disease recurrent 


of the temporal lobe 




attacks of vertigo, hearing loss and 


a- are asymptomatic and discovered 




tinnitus associated with nausea and 


accidentally during mastoidectomy 




vomiting 


b- present with persistent ipsilateral 
temporal headach 











41 



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iUaJl 3l£| 


52-Before tympanoplasty in a 30 




c-retraction pocket 


years old patient, the following is 




d-tympanosclerosis 


required 






a- audiogram 




58-By modified radical 


b- ensure dry perforation 




mastoidectomy we mean 


c-treatment of any underlying nasal 




a- removal of mastoid air cells and ali 


or paranasal sinüs infection 




middle ear contents 


d-all of theabove 




c- removal of diseased mastoid air 


e- non of the above 




cells 

c- removal of mastoid air cells and ali 


53-The XI, X and XI cranial nerves 




middle ear contents with preservation 


may be involved in ali of the following 




of healthy remnants of tympanic 


except 




membrane and ossicles 


a-acoustic neuroma 




d- non of the above 


b-transverse temporal bone fracture 






c-malignant otitis externa 




59-By radical mastoidectomy 


d- squamous celi carcinoma of the 




operation we mean 


middle ear 




a- removal of mastoid air cells and ali 


-in transverse temporal bone fracture 




middle ear contents except stapes 


the involved nerves are VII & VIII 




b- removal of diseased mastoid air 

cells 

c- removal of mastoid air cells and ali 


54-ln lower motor neurone facial 




paralysis with intact taste sensation 




middle ear contents with preservation 


at the anterior 2/3 of the tongue, the 




of healthy remnants of tympanic 


level of the lesion is : 




membrane and ossicles 


a- in the internal auditory canal 




d- non of the above 


b-in the horizontal tympanic part 






c- in the vertical part above the 




60-Extensive cholesteatoma is best 


stapes 




treated by 


d- in the stylomastoid foramen 




a- cortical mastoidectomy 
b- radical mastoidectomy 


55-Failure to close the eye voluntarily 




c- modified reducal mastoidectomy 


is a symptom of 




d- myringotomy wiyh insertion of T 


a- paralysis of the trigeminal nerve 




tu be 


b- upper motor neurone facial 






paralysis 


__^^ 


61-Which of the following statements 


c- lower motor neurone facial 


mâ 


is false concerning Cochlear implant 


paralysis 


| I 


a-postlingually deaf get far better 


d- non of the above 


benefit than prelingually deaf 




^JL 


b-it is indicated in total sensory 


56-Uncontrolled diabetes in elderly 




hearing loss 


patient may predispose to 




c-the auditory nerve should be intact 


a- cholesteatoma 




d- After the operation speech 


b- malignant otitis externa 




discrimination is good and lip 


c- presbyacusis 




reading is not needed 


d- vestibular neuronitis 




62-Which of the following statements 


57-A large near total perforation 




is wrong concerning myringotomy 


following acute necrotizing otitis 




Operation : 


media must be followed up for fear of 




a- it is indicated in acute suppurative 


a- recurrent middle ear infection 

b- secondary acguired cholesteatoma 




otitis media with bulging drum 







42 



j^U\ }\£\ 



b- it is indicated in secretory otitis 




b-Loop Diuretics. 


media after failure of medical 




c-Aminoglycosides. 


Treatment 




d-NSAlD. 


c- it is better done in the postero 




e-AII of the above 


superior quadrant of the tympanic 






membrane 




65-Which of the following is 


d-residual perforation of the tympanic 




associated with objective tinnitus 


membrane is one of its complications 




a-Meniere's disease. 
b-Ear wax impaction. 


63-Etiology for pulsatile tinnitus 




c-Acoustic neuroma. 


includes the followings except: 




d-Palatal myoclonus. 


a) Arteriovenous malformation of 




e-Middle ear effusion 


neck. 






b) Otosclerosis. 




66-The following have an ototoxic 


c) Glomus jugulare tumors. 




effect except 


d) Hyperthyroidism. 


m 


a- gentamycin 


e) Atherosclerosis. 


b- frusemide 






c- streptomycin 


64-Which of the following drugs are 




d- amoxicilline 


known to cause tinnitus? 
a-Salicylates. 




e- quinine 











If u have more MCQs : share with us at 



http://groups.yahoo.com/group/medshams/ 



100 CASES İN EAR, NOSE & THROAT 

by 

Prof Dr Hassan Wahba 

Professor of OtoRhinoLaryngology 

Faculty of Medicine Ain Shams University 



Case 1 : A 10 year old child was having a right mucopurulent otorhea for the last 4 
years. A week ago he became dizzy with a whirling sensation, nausea, vomiting 
and nystagmus to the opposite side; his deafness became complete and his 
temperature was normal. Three days later he became feverish, irritable and 
continuously crying apparently from severe headache. Also he had some neck 
retraction. The child was not managed properly and died by the end of the week. 



CASE1 
Diagnosis & 
reasons 



Right chronic suppurative otitis media (mucopurulent otorhea of 
4 years duration) complicated by suppurative labyrinthitis 
(dizziness, nausea and vomiting with nystagmus to the opposite 
side and complete loss of hearing) and then complicated by 
meningitis (fever, severe headache and neck retraction). 



Explain the 

following 

manifestations 



VVhirling sensation: vertigo due to inner ear inflammation 
Nystagmus to the opposite side: suppurative labyrinthitis 
leading to fast phase of eye movement to the opposite ear and 
slow phase to the diseased ear nystagmus direction is called 
according to the fast phase. İn serous labyrinthitis with no inner 
ear celi destruction the direction of nystagmus is toward the 
diseased ear. 

-43- 



j^U\ }\£\ 





Severe headache: increased intracranial pressure due to 

meningitis 

Neck retraction: due to meningeal inflammation 


Further 
examination 
&/or 
investigations 


• Otologic examination possible finding of a marginal 
perforation of atticoantral CSOM (cholesteatoma) 

• Audiogram to reveal SNHL in the affected ear 

• Kernig's and Brudzinski's signs 

• Fundus examination to show papilledema 

• Lumbar puncture: turbid high pressure CSF with pus rich 
in proteins 

• Complete blood picture 


Treatment 


Antibiotics that cross the blood brain barrier 

Analgesics 

Repeated lumbar puncture to drain infected CSF and to relieve 

symptoms and to inject antibiotics 

Treaetment of the underlying otitis media appropriately 

according to its type 







Case 2: A 50 year old male patient complained of right earache of 2 days duration. 
The pain was especially severe on chewing food and during speech. There was 
also marked edema of the right side of the face. On examination, pressure on the 
tragus was painful; and there was a small red swelling arising from the anterior 
external auditory meatal wall. Rinne test was positive in the right ear. The patient 
gave a history of 2 previous similar attacks in the same ear during the last six 
months but less severe. 



CASE 2 



Diagnosis & 
reasons 



Recurrent furunculosis of the right external auditory canal (pain 
in the ear with movements of the temporomandibular joint or 
pressure on the tragus, edema of the face and a small red 
svvelling in the anterior wall of the external auditory canal) 



Explain the 

following 

manifestations 



Severe pain on chewing food: movements of the 

temporomandibular joint lead to movements of the cartilaginous 

external auditory canal that is lined by skin containing hair 

follicles from which the furuncle arises. 

Edema of the right side of the face: extension of the 

inflammatory edema to the face in severe cases 

Rinne positive: means normal hearing and NO conductive 

hearing loss because when air conduction is better than bone 

conduction it is called Rinne positive 

Previous similar attacks: recurrence the most probable cause is 

Diabetes mellitus 



Further 
examination 
&/or 
investigations 



Otoscopic examination of the tympanic membrane if 

possible 

Blood glucose analysis to discover diabetes 



Treatment 



Antibiotics 

Analgesics 

Never incise or excise for fear of perichondritis 

Local antibiotic or glycerine icthyol ointment 

Proper control of diabetes if discovered 



44 



Case 3: A 10 year old child complained of a right mucopurulent otorhea for the 
last 2 years. He suddenly became feverish and this was associated with 
diminution of the ear discharge. There was also tenderness on pressure behind 
the auricle. The retroauricular sulcus was preserved. There was no retroauricular 
fluctuation. 



CASE 3 


Diagnosis & 
reasons 


Right chronic suppurative otitis media (mucopurulent discharge 
of 2 years duration) complicated by mastoiditis (fever with 
decreased ear discharge, tenderness behind the auricle with 
preservation of retroauricular sulcus; it is not an abscess 
because there is no retroauricular fluctuation). 


Explain the 

follovving 

manifestations 


Diminution of ear discharge: reservoir sign dischrge decreases 
but is stili there and whenever discharge decreases fever and 
other constitutional symptoms increase in intensity 
Tenderness behind the auricle: due to inflammation of the bone 
of the mastoid process and its overlying periosteum 
Retroauricular sulcus preserve: as the inflammatory process is 
subperioteal 

No retroauricular fluctuation: it is mastoiditis and so is not a 
mastoid abscess yet 


Further 
examination 
&/or 
investigations 


• Otoscopic examination of the ear possible finding of a 
cholesteatoma 

• Look for the rest of the manifestations of mastoiditis as 
sagging of the posterosuperior wall of the bony external 
auditory canal 

• CT scan of the ear to show opacity in the mastoid bone 

• Complete blood picture 


Treatment 


Medical treatment in the form of antibiotics and 
Drainage of the ear through myringotomy and 
Mastoidectomy is essential to remove ali disease from the ear 



Case 4: A 9 year old child has been complaining of right continuous offensive ear 
discharge for the last 3 years. A month ago he began to suffer from headache, 
fever and some vomiting for which he received symptomatic treatment. The 
patient's condition was stable for a while, then after 2 weeks he started to suffer 
from severe headache and drowsiness. The patient also noticed difficulty going 
up and down the stairs. A week later, he developed weakness in the left arm and 
left leg, and became markedly drovvsy. He became comatose the next day. 



CASE 4 



Diagnosis & 
reasons 



Right atticoantral (cholesteatoma) chronic suppurative otitis 
media (continuous offensive ear discharge for 3 years) 
complicated by right temporal lobe abscess (manifestations of 
increased intracranial tension with weakness in the opposite 
side of the body on the left arm and leg) 



Explain the 

follovving 

manifestations 



Initial headache fever and vomiting: indicates the initial stage of 

a brain abscess formation in the stage of encephalitis 

Stable condition of 2 weeks: latent phase of brain abscess with 

decreased symptoms 

Severe headache and vomiting after 2 weeks: manifestations of a 

formed brain abscess leading to increased intracranial tension 

Difficulty going up and down the stairs: due to hemipareisis 

(vveakness) in the opposite left leg to the diseased ear 

-45- 



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Comatose: final stage of brain abscess 



Further 
examination 
&/or 
investigations 

Treatment 



• Otoscopic examination of the ear 

• CT scan with contrast to locate the brain abscess 

• Complete blood picture to show leucocytosis very good to 
know prognosis with treatment 

• Fundus examination to show papilledema 

Antibiotics that cross the blood brain barrier 

Drainage or excision of the brain abscess neurosurgically 

Tympanomastoidectomy to remove the cholesteatoma from the 

ear 

Avoid lumbar puncture as it might lead to conization of the 

brainstem and death 



Case 5: A 6 year old child developed severe pain in both ears together with a rise 
of temperature (39 C) following an attack of common cold. The child received 
medical treatment that lead to drop of his temperature and subsidence of pain; so 
the physician stopped the treatment. However, the mother noticed that her child 
did not respond to her except when she raised her voice. This decreased 
response remained as such for the last 2 weeks after the occurrence of the 
primary condition. 



CASE 5 
Diagnosis & 
reasons 

1 



Common cold leading to bilateral acute suppurative otitis media 
(fever and earache) complicated by nonresolved acute otitis 
media or otitis media with effusion (only symptom is a hearing 
loss) 



Explain the 

following 

manifestations 



Ear condition following common cold: due to extension of 
infection along eustachian tube 

Decreased response to sound: fluid due to non resolved acute 
otitis media behind the drum leads to decreased vibration of the 
tympanic membrane 



Further 
examination 
&/or 
investigations 



Otoscopic examination will reveal in the primary condition 

a congested maybe bulging tympanic membrane and in 

the secondary condition a retracted drum showing afluid 

level with loss of lustre 

Audiogram will show an air bone gap indicating a 

conductive hearing loss 

Tympanogram will show either a type C (negative peak) or 

a type B (flat) curves 

X-ray of the nasopharynx might reveal an underlying 

adenoid enlargement specially if the condition is recurrent 



Treatment Continue antibiotic treatment until hearing returns to normal 

May combine treatment with antihistamines, corticosteroids and 

mucolytics 

Insertion of ventillation tubes (grommet) in the drum if condition 

persistent or recurrent 

Usage of tubes relies on tympanometry findings if the curve is 

type B flat curve 

Adenoidectomy is required if there is an enlarged adenoid 

obstructing the eustachian tube 

Case 6: A 3 year old boy presented to the ENT specialist because of an inability to 
close the right eye and deviation of the angle of the mouth to the left side upon 

-46- 



crying of 2 days duration. His mother reported that he had severe pain in the right 
ear 5 days prior to his present condition. She also added that his earache 
improved on antibiotic therapy. 



CASE6 


Diagnosis & 
reasons 


Right acute suppurative otitis media (earache that improved with 
antibiotics of 2 days duration) complicated by right lower motor 
neuron facial paralysis (inability to close the right eye and 
deviation of the angle of the mouth to the left side) 


Explain the 

follovving 

manifestations 


İnability to close the right eye: paralysis of the orbicularis occuli 

muscle supplied by the facial 

Deviation of the angle of the mouth to the left: muscles of the 

orbicularis oris of the left non paralysed side pull the mouth to 

the left side 

Onset of paralysis 5 days only after the original condition: due 

to pressure of the inflammatory exudate in the middle ear on a 

dehiscent (exposed) facial nerve 


Further 
examination 
&/or 
investigations 


• Otoscopic examination may show a congested bulging 
tympanic membrane 

• Examination of the rest of the facial nerve to diagnose the 
proper level of paralysis 

• Electroneuronography of the facial nerve to estimate the 
degree of damage 

• Audiogram and tympanogram 


Treatment 


Urgent myringotomy to drain the middle ear and allow for facial 

nerve recovery 

Antibiotics for acute suppurative otitis media preferabley 

according to culture and antibiotic sensitivity 

Çare of the eye during period of paralysis by eye drops, ointment 

and covering of the eye 



Case 7: A 30 year old female complained of bilateral hearing loss more on the 
right side following the delivery of her first child; hearing loss was marked in 
quiet places but hearing improved in a noisy environment. Both tympanic 
membranes shovved a normal appearance. Rinne tuning fork test was negative. 



CASE 7 


Diagnosis & 
reasons 


Bilateral otosclerosis (hearing loss related to pregnancy, more 
marked in quiet environment, normal tympanic membranes, 
Rinne tunning fork test negative that is bone conduction better 
than air conduction indicating conductive hearing loss) 


Explain the 

follovving 

manifestations 


Hearing loss marked in quiet places: patient has conductive 

hearing loss in noisy environment the speaker usually raises his 

voice and so patient hears better (paracusis VVilsii) 

Normal appearance of both tympanic membranes: this is the 

common finding in rare cases a reddish tympanic memebrane 

may be present called Schvvartze's sign (flamingo red 

appearance) 

Rinne tunning fork test negative: that is bone conduction better 

than air conduction indicating conductive hearing loss 


Further 
examination 
&/or 
investigations 


• Other symptoms (tinnitus, sensorineural hearing loss, 
vertigo) 

• Audiogram shovvs either air bone gap indicating 
conductive hearing loss or low bone curve indicating 



47 



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sensorineural hearing loss or both indicating mixed 

hearing loss 

Tympanogram usually shows type As with stunted type 

curve 

CT scan may show decreased density of the bone around 

the inner ear (otospongiotic focus) indicating activity of 

the disease 



Treatment 



Stapedectomy (the best) if hearing loss is conductive or mixed 

Hearing aid if patient refuses surgery or has püre sensorineural 

hearing loss 

Medical treatment to stop progression of the disease (fluoride 

therapy) if disease is extensive 

Avoid contraceptive pille and preganacy in order to limit the 

disease 



Case 8: After a car accident a young male complained of inability to close the 
right eye and deviation of the angle of the mouth to the left side together with 
dribbling of saliva from the right angle of the mouth. There was also a right 
hearing loss and a blood clot was found in the right external auditory canal. 3 
days later a clear fluid appeared in the right ear that increased in amount on 
straining. A day later the patient was drowsy and developed fever and neck 
stiffness. 



CASE 8 


Diagnosis & 
reasons 


Longitudinal fracture of the right temporal bone (accident, blood 
in external auditory canal and hearing loss) complicated by right 
lower motor neuron facial paralysis ( inability to close the right 
eye and deviation of the angle of the mouth to the left side) and 
complicated by CSF otorhea (clear fluid in the right external 
auditory canal that increased with straining) and later 
complicated by meningitis (drowzy, fever and neck stiffness) 


Explain the 

follovving 

manifestations 


Dribbling of saliva from angle of mouth: due to facial nerve 
paralysis leading to inability to coapte the lips so angle of mouth 
is öpen and droops downwards with escape of saliva outwards 
Hearing loss: most probably due to longitudinal fracture causing 
tympanic membrane perforation and auditory ossicular 
disrruption leading to conductive hearing loss also the blood 
clot may cause obstruction of the external auditory canal leading 
to conductive hearing loss 

Clear fluid increases with straining: CSF otorhea as CSF 
pressure increases with straining causing increase in the 
otorhea 
Neck stiffness: due to meningeal irritation and inflammation 


Further 
examination 
&/or 
investigations 


• CT scan to diagnose the fracture and study its extent 

• Topognostic testa for the facial nerve as (Shirmer's, 
stapedius reflex,....) to know the level of paralysis 

• Electroneuronography: to study the electrophysiologic 
status of the facial nerve 

• Audiogram: to know the type of hearing loss 

• Examination of fluid dripping from the ear 

• Lumbar puncture: increased pressure of turbid pus 
containing CSF 


Treatment 


Treatment of meningitis: antibiotics, lower CSF pressure by 



48 



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repeated lumbar puncture, diuretics and mannitol 10% 
Treatment of CSF otorhea: semisitting position, avoid straining, 
diuretics and close observation of the patient regarding fever 
and neck stiffness for the development of meningitis 
Treatment of facial nerve paralysis: çare of the eye, surgical 
exploration and repair if electroneuronography reveals 90% 
degeneration of the affected nerve within one week of the onset 
of paralysis 

Treatment of hearing loss: tympanoplasty if the hearing loss or 
tympanic membrane perforation persists for more than 6-8 
vveeks 



Case 9: A 28 year old male has been complaining of hearing loss in the left ear for 
the last 6 years. The hearing loss was progressive in nature and accompanied by 
tinnitus. During the last 6 months there was swaying during walking to the left 
side, a change in his voice and an inability to close the left eye with deviation of 
the angle of the mouth to the right side. Otologic examination showed no 
abnormality. The corneal reflex was lost in the left eye. 



CASE 9 



Diagnosis & 
reasons 



Left acoustic neuroma (progressive history of hearing loss över 
6 years followed by imbalance due to cerebellar manifestations 
and developing neurological manifestations) 



Explain the 

following 

manifestations 



Hearing loss of 6 years duration: pressure of the tumor on the 
eighth nerve responsible for hearing and balance 
Swaying during walking to the left side: cerebellar attaxia 
alaways to wards the side of the lesion due to weakness 
(hypotonia) of the muscles on the same side of the lesion 
Change of voice: intracranial vagus paralysis leading to vocal 
fold paralysis 

İnability to close the eye: left lower motor neuron paralysis as 
the facial nerve accompanies the vestibulocochlear nerve in the 
internal auditory canal 

Absent sorneal reflex in the left eye: due to facial or trigeminal 
paralysis with trigeminal paralysis the contralateral reflex is lost 
as well as the patient can not feel in the affected left cornea 



Further 
examination 
&/or 
investigations 



MRI of the internal auditory canals, cerebellopontine 

angles and inner ears 

CT scan if MRI is not available 

Audiological evaluation especially auditory brainstem 

response 

Electrophysiological tests for the facial nerve 



Treatment 



Excision of the neuroma 

İn old patients another option is the gamma knife (directed 

radiotherapy) to limit growth of the tumor 

İn young patients with small tumors that do not produce new 

symptoms other than hearing loss it is advised to follow up the 

case with MRI on a 6-12 month basis as most of the tumors do 

not grow and so do not reguire surgery or gamma knife 



Case 10: A 35 year old female suddenly complained of an attack of bleeding from 
her right ear (otorrhagia). An ENT specialist packed the ear and after removal of 
the pack found an aural polyp. The patient also complained of pulsatile tinnitus in 



49 



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the right ear of 2 years duration and a change in her voice of 2 months duration. 
On laryngeal examination there was right vocal fold paralysis, the vocal fold was 
found in the abduction position. No lymph node enlargement was found in the 
neck. 



CASE10 



Diagnosis & 
reasons 



Right glomus jugulaire tumor (blleding from the ear, pulsatile 
tinnitus and neurological manifestations of the jugular foramen 
syndrome) 



Explain the 

following 

manifestations 



Aural polyp: this is not an inflammatory polyp it is extension of 
the tumor mass in the external auditory canal when touched by 
any instrument will cause severe bleeding 
Pulsatile tinnitus: the sound heard by the patient is that of the 
blood flowing in the very vascular tumor mass the sound 
disappears when the jugular vein in the neck is compressed or 
when there is a sensorineural hearing loss in the ear 
Abduction position of the vocal fold: due to a complete vagus 
paralysis paralysing ali muscles of the right hemilarynx and so 
the vocal fold rests in the cadaveric abduction position 
No lymph node enlargement: glomus is a benign tumor there is 
no lymph node metastasis 



Further 
examination 
&/or 
investigations 



• CT scan with contrast to know the extent of the tumor 

• MRI and MR angiography (MRA) 

• Angiography to know the feeding vessels of the tumor 

• Examination of the entire body for a possible associated 
chromafffin tissue tumors as phaechromocytoma 
especially in aptients that are hypertensive 



Treatment 



Excision of the tumor via the infratemporal approach according 
to its extent 



Case 11 : A 30 year old female has been suffering from seasonal nasal obstruction 
for the last few years. A watery nasal discharge and attacks of sneezing 
accompanied this nasal obstruction. 2 weeks ago she had an attack of common 
cold, she refused to have medical treatment and 2 days later she began to 
develop pain över the forehead and a mild fever. She did not receive any 
treatment and so recently developed severe headache with a high fever (40 C) 
and became severely irritable and could not withstand light. On examination there 
was marked neck and back stiff ness. 



CASE 11 


Diagnosis & 
reasons 


Nasal allergy (seasonal, watery nasal discharge, sneezing and 
nasal obstruction) complicated by acute frontal sinusitis (mild 
fever, and pain över the forehead) and later complicated by 
meningitis (high fever, irritability, can not vvithstand light and 
neck and back stiff ness) 


Explain the 

follovving 

manifestations 


VVatery nasal discharge: due to edematous fluid of nasal allergey 

that pours from the nose after accumulating in the nasal mucosa 

Pain över the forehead: due to inflammation of the frontal sinüs 

it could be a continuous pain of the inflammation or a morning 

vacuum headache 

Could not vvithstand light: photophobia that occurs with 

meningitis 


Further 
examination 


• Lumbar puncture: increased pressure of turbid pus 
containing CSF 



50 



&/or 
investigations 



CT scan to diagnose frontal sinusitis 

Complete blood picture to show leucocytosis 

Fundus examination 

After management of acute condition investigations for 

allergy (skin tests, RAST, ) 



Treatment 



Treatment of meningitis (antibiotics, lower intracranial tension 
by repeated lumbar puncture diuretics mannitol 10%) 
Treatment of frontal sinusitis (functional endoscopic sinüs 
surgery or öpen surgery) 

Treatment of underlying predisposing cause which is nasal 
allergy (avoid the cause of allergy, hyposensitization, 
pharmacotherapy by local or systemic steroids, antihistamines, 
mast celi stabilizers, ) 



Case 12: A 25 year old patient had been complaining from severe acute rhinitis. 
On the fifth day he started to get severe headache, mild fever and marked pain 
över the left forehead. The patient did not receive any treatment and on the tenth 
day started to get repeated rigors and became severely ili. On examining the 
patient the following signs were detected: 

• A large red tender swelling in the right nasal vestibule. 

• Marked edema of both upper and lower right eye lids. 

• Chemosis of the conjunctive in the right eye. 
Forvvard proptosis of the right eyeball. 



CASE 12 


Diagnosis & 
reasons 


Acute rhinitis complicated by two conditions: left frontal 
sinusitis (pain över the left forhead and mild fever) the second 
condition is right nasal furuncle due to excessive nasal 
secretions leading to fissures and bacterial infection in the nasal 
vestibule (a large tender swelling in the right nasal vestibule) the 
furuncle on the tenth day is complicated by cavernous sinüs 
thrombosis (rigors, severely ili, edema of the right eye lids, 
chemosis of the conjunctive, proptosis of the right eyeball) 


Explain the 

follovving 

manifestations 


Rigors: is an indication that infection has reached the blood 

stream 

Chemosis of the conjunctiva: congestion and edema of the 

conjunctiva due to obstruction of the orbital veins that drain into 

the cavernous sinüs 

Proptosis of the right eyeball: due to obstruction of the venous 

drainage of the eye via the retrorbital veins that drain into the 

cavernous sinüs 


Further 
examination 
&/or 
investigations 


CT scan 

Blood culture 

Leucocytic count 

Fundus examination will show engorged retinal veins 


Treatment 


Hospitalization 

Intravenous antibiotics 

Anticoagulants 

Local antibiotic ointment to help furuncle to drain 

Treatment of frontal sinusitis 



Case 13: An 18 year old male patient complained of dull aching pain över the 
forehead for the last 3 years. This pain increased in the morning and decreased in 

-51 - 



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the afternoons, together with intermittent nasal discharge. 10 days ago the pain 
became very severe with complete nasal obstruction and fever 38 C the patient 
did not receive the proper treatment and by the tenth day became drowsy with 
some mental behavioral changes, also there was vomiting and blurred vision. 



CASE13 


Diagnosis & 
reasons 


Chronic frontal sinusitis (3 years duration, typical vacuum 
morning headaches) complicated recently (10 days ago, 
complete nasal obstruction, fever 38 C) the latest complication is 
a frontal lobe abscess (drowsy, mental behavioral changes, 
vomiting and blurred vision) 


Explain the 

follovving 

manifestations 

Ta 


Morning headache: due to obstruction of the opening of the 
frontal sinüs when the patient sleeps the opening is tightly 
closed due to edema and the air in the sinüs is absorbed 
creating a negative pressure that causes headache in the 
morning when the patient stands up the edema is somewhat 
relieved and air enters the sinüs and so the headache disappears 
or decreases in the afternoon 

Mental behavioral changes: the abscess causes pressure on the 
centers in the frontal lobe of the brain that is responsible for 
behavior 

Blurred vision: increased intracranial tension by the abscess 
causing vomiting and papilledema 


Further 
examination 
&/or 
investigations 


• Tenderness över the frontal sinüs 

• CT scan with contrast to locate the abscess and diagnose 
the frontal sinusitis 

• Leucocytic count important after administering treatment 
for prognosis 


Treatment 


Neurosurgical excision or drainage of the abscess 
Treatment of frontal sinusitis both medically by antibiotics and 
surgically to drain the frontal sinüs 



Case 14: A 52 year old male started to develop right sided progressively 
increasing nasal obstruction 6 months ago. This was followed by blood tinged 
nasal discharge from the right side as well. Due to looseness of the right second 
upper premolar tooth, the patient consulted a dentist who advised extraction, this 
resulted in an oroantral fistula. On examination there was a firm tender swelling 
in the right upper neck. 



CASE 14 



Diagnosis & 
reasons 



Cancer of the right maxillary sinüs (right blood tinged nasal 
discharge, looseness of right upper second premolar tooth, 
svvelling in the right upper neck) 



Explain the 

follovving 

manifestations 



Blood tinged nasal discharge: common early manifestation of 

cancer of the paranasal sinuses due to the presence of necrotic 

infected nasal mass 

Looseness of the right upper second premolar tooth: due to 

destruction of the root of the tooth by the malignant tumor as 

this tooth and the first molar are very close to the floor of the 

maxillary sinüs 

Oroantral fistula: due to destruction of the alveolus and the 

palate by the malignant tumor leading to escape of saliva food 

and drink from the mouth to the maxillary antrum and then back 

out of the nose 



52 



j^U\ }\£\ 





Firm tender swelling in the right upper neck: lymph node 
metastasis from the primary maxillary tumor it could be tender or 
not tender 


Further 
examination 
&/or 
investigations 


• Other symptoms include: orbital manifestations as 
diplopia, blindess and pain; headache and trigeminal 
neuralgic pain; swelling of the cheek; Horner's syndrome 
due to spread of malignancy from the retropharyngeal 
lymph node of Rouviere to the upper cervical sympathetic 
ganglion 

• CT scan: to diagnose, study the extent of the malignant 
lesion and its relation to the big blood vessels of the neck 
and look for other lymph node metastasis 

• Nasal endoscopy and biopsy to prove malignancy prior to 
treatment and to know the pathological type of the 
malignant tumor before deciding on the modality of 
treatment 

• General investigations to assess condition of the patient 


Treatment 


Surgical excision by maxillectomy (partial, total or radical 

according to tumor extent) 

Radiotherapy for extensive inoperable lesions 

Radical neck dissection for lymph node metastases 

Chemotherapy for inoperable tumors that do not respond to 

radiotherapy 

Palliative treatment for inoperable terminal cases 







Case 15: A 40 year old female has been complaining of nasal troubles of a long 
duration in the form of bilateral nasal obstruction, anosmia and nasal crustation. 
2 months ago she developed mild stridor that necessitated a tracheostomy later 
on. She received medical treatment for her condition, but 1 month later developed 
severe to profound hearing loss that necessitated the use of a hearing aid. 



CASE 15 


Diagnosis & 
reasons 


Rhinolaryngoscleroma (nasal crustations of long duration, 
stridor) 


Explain the 

follovving 

manifestations 


Nasal obstruction: due to the presence of a scleroma mass or 

crustation or nasal synechia 

Stridor: laryngoscleroma causes subglottic stenosis and fibrosis 

causing biphasic stridor 

Profound hearing loss that necessitated a hearing aid: an old 

antibiotic used for the treatment of scleroma was streptomycin 

that was ototoxic causing sensorineural hearing loss now 

rifampscin is used with no such side effect 


Further 
examination 
&/or 
investigations 


• Examination of the nose shows crusts, nasal mass, 
offensive discharge 

• Examination of the larynx will show an area of subglottic 
stenosis may be in the form of a web 

• Biopsy: will show a chronic inflammatory process with 
endarteritis obliterans and two diagnostic structure the 
Mickulicz celi and the Russel body; the active celi the 
fibroblast is also seen 


Treatment 


Medical: Rifampscin 300mgm daily twice daily before meals 
Surgical: recanalization of the nose to relieve nasal obstruction 
Laser excision of the subglottic web to relieve dyspnea and 



53 



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stridor 

Follow up the condition until complete cure 



Case 16: A 24 year old male patient presented because of severe pain in the 
throat and the left ear that increased with swallowing of sudden onset and 2 days 
duration. He gave a history of sore throat and fever a few days prior to the 
condition. On examination, the patient looked very ili and has a thickened voice. 
The temperature was 39.5 C and the pulse 1 1 0/minute. The patient had fetor of the 
breath and was unable to öpen his mouth. There was marked edema of the palate 
concealing the left tonsil that was found injected. There was a painful hot 
swelling located below the left angle of the mandible. The left tympanic 

membrane was normal. 

CASE 16 



Diagnosis & 
reasons 



Acute tonsillitis (sore throat and fever) complicated by 
peritonsillar abscess {quinzy} (severe throat pain referred to the 
left ear, very ili, thickened voice, fever, fetor, unable to öpen his 
mouth, edema of the palate, painful hot swelling at the angle of 
the mandible) 



Explain the 

following 

manifestations 



Pain in the left ear: refeered earache along Jackobsen's 

tympanic branch (that supplies the middle ear) of the 

glossopharyngeal nerve (that supplies the palatine tonsil) 

Thickened voice: due to palatal edema 

Fetor of the breath: severe dysphagia leading to inability to 

swallow saliva together with the presence of an abscess in the 

oropharynx 

Unable to öpen his mouth: trismus due to irritation of the medial 

pterygoid muscle by the pus under tension in the peritonsillar 

abscess 

Left tonsil injected: markedly congested due to severe 

inflammatory process 

Hot swelling below the left angle of the mandible: jugulodigastric 

lymph adenitis 

Normal tympanic membrane: there is no acute otitis media pain 

in the ea is referred from the throat 



Further 

examination 

&/or 

investigations 

Treatment 



• Complete blood picture lecocytosis 

• CT scan 



Medical treatment: antibiotics, analgesics, antipyretics and 

antiinflammatory drugs 

Surgical drainage of the quinzy (pus pointing, palatal edema, 

throbbing pain, pitting edema) 

Tonsillectomy after 2-3 vveeks 



Case 17: A 5 year old boy was referred to an ENT specialist because of mouth 
breathing and impairment of hearing of 2 years duration. His mother reported that 
her child has almost constant mucoid nasal discharge that sometimes changes to 
a mucopurulent one and he snores during his sleep. On examination, the child 
has nasal speech and obvious mouth breathing. Examination of the ears showed 

retracted tympanic membranes. Tympanograms were flat type B. 

CASE 17 



Diagnosis & Adenoid enlargement (mouth breathing, nasal discharge, 



54 



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reasons 



snoring, nasal speech) complicated by bilateral otitis media with 
effusion (impairement of hearing, retracted tympanic membranes 
type B tympanograms) 



Explain the 

following 

manifestations 



Mucoid nasal discharge that can change to be mucopurulent: 

adenoid enlargement may be complicated by ethmoiditis causing 

the mucopurulent nasal discharge 

Snoring: due to bilateral nasal obstruction during his sleep can 

progress to respiratory obstruction during his sleep (sleep 

apnea) 

Nasal speech: rhinolalia clausa due to nasal obstruction were 

the letter m is pronounced as b 

Type B tympanograms: due to presence of fluid behind the intact 

retracted tympanic membrane leading to no vibrations of the 

drum — 



Further 
examination 
&/or 
investigations 



j 



Other symptoms and signs: adenoid face, stunted growth, 

poor scholastic achievement, nocturnal enuresis, 

X-ray lateral view skull: soft tissue shadow in the 

nasopharynx causing narrowing of the nasopharyngeal 

airvvay 

Audiogram: air bone gap indicating conductive hearing 

loss 



Treatment 



Adenoidectomy 

Bilateral ventillation tube (grommet) insertion in the tympanic 

membranes 



Case 18: A male patient 49 year old presented with the complaint of enlargement 
of the upper deep cervical lymph nodes on both sides of the neck of 6 months 
duration. The nodes appeared first on the right side later on the other side. The 
patient gave a history of decreased hearing in the right ear that was intermittent 
but later became permanent. Recently he developed diminution of hearing in his 
left ear, nasal regurge, nasal intonation of voice and recurrent mild nosebleeds. 



CASE 18 


Diagnosis & 
reasons 


Nasopharyngeal carcinoma with lymph node metastasis (early 
appearance of lymph node metastasis as the nasopharynx is one 
of the silent areas of the head and neck - occult primary sites; 
decreased hearing due to eustachian tube affection) 


Explain the 

follovving 

manifestations 


Bilateral enlargement of upper deep cervical lymph nodes: the 

nasopharynx may send metastasis to both sides because it is 

present in the center of the head and neck 

Decreased hearing in the right ear: due to eustachian tube 

destruction by the malignant tumor causing right otitis media 

with effusion and a retracted tympanic membrane leading to a 

conductive hearing loss 

Nasal regurge: due to palatal paralysis 

Nasal intonation of voice: due to nasal obstruction and palatal 

paralysis it is a combined rhinolalia clausa and aperta 


Further 
examination 
&/or 
investigations 


• CT scan 

• Nasopharyngoscopy and biopsy 

• Audiogram and tympanogram 

• General investigations 


Treatment 


Radiotherapy for the primary nasopharyngeal carcinoma 
Radical neck dissection for residual lymph node metstasis after 



55 



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treatment with radiotherapy 

Chemotherapy in certain selected cases according to 

histopathological finding of biopsy 

Palliative treatment for terminal cases 



Case 1 9: A 40 year old female began to experience diff iculty in swallowing for the 
last 3 years. This difficulty in swallowing was to ali kinds of food and the 
condition showed variation in the degree of dysphagia and was associated with a 
sense of obstruction at the root of the neck. For the last 2 months, she developed 
rapidly progressive difficulty in swallowing even to fluids together with a change 
in her voice. Recently she noticed a firm non-tender swelling in the right upper 
neck. 



CASE 19 


Diagnosis & 
reasons 


Plummer - Vinson disease (dysphagia of intermittent nature for 3 
years to ali kinds of food) leading to hypopharyngeal or 
esophageal malignancy ( progression of dysphagia in the last 2 
months, change of voice, appearance of neck swelling indicating 
lymph node metastasis) 


Explain the 

follovving 

manifestations 


Sense of obstruction at the root of the neck: the level of 

obstruction in Plummer Vinson disease is due to the presence of 

pharyngeal and esophageal webs of fibrous tissue in the lower 

pharynx and upper esophagus 

Change of voice: due to malignant involvement of the recurrent 

laryngeal nerve leading to vocal fold paralysis 

Firm non tender swelling in the right upper neck: lymph node 

metastasis in the right upper deep cervical lymph node 


Further 
examination 
&/or 
investigations 


• Indirect laryngoscopy: tumor is seen in the hypopharynx 
with overlying froth 

• Direct laryngoscopy and biopsy 

• X-ray lateral view neck showing a wide prevertebral space 
displacing the airway anteriorly 

• CT scan to show extent of the tumor especially lower 
extent 

• Barium swallow 

• General investigations to assess the general condition of 
the patient 


Treatment 


Surgical excision by total laryngopharyngectomy and radical 

neck dissection of metastatic lymph nodes 

Radiotherapy 

Chemotherapy 

Palliative treatmet 

Type of treatment depends on general condition of patient, age 

of patient, extent of tumor and its histopathological type 



Case 20: 4 hours follovving an adenotonsillectomy for a 6 year old the pulse was 
110/min, blood pressure 100/70, respiration 20/min and the child vomited 250 cc 
of a dark fluid. 2 hours later he vomited another 150 cc of the same dark fluid, the 
pulse became 130/min, the blood pressure became 80/50. The respiration rate 
remained 20/min. 



CASE 20 
Diagnosis & 
reasons 



Post-tonsillectomy reactionary hemorrhage (rising pulse, 
lovvering of blood pressure, vomiting of altered blood, 4 hours 

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following an adenotonsillectomy) 


Explain the 

following 

manifestations 


Pulse is 110/min then rises to 130/min: a continuous rising pulse 
is due to tacchycardia as a compensation for the blood loss 
Vomiting of dark fluid: altered blood (acid hematin when blood is 
changed by stomach HCL) 


Further 
examination 
&/or 
investigations 


• Examination of the throat site of bleeding may be from the 
tonsil bed or from the adenoid bed 

• Rapid assessment of hemoglobin 


Treatment 


Antishock measures (fluid and blood transfusion, steroids, 

coagulants) 

Surgical hemostasis under general anesthesia 



Case 21 : A 3 year old child was referred to an ENT specialist because of cough, 
difficulty of respiration and temperature 39.5 C of few hours duration. The child 
was admitted to hospital for observation and medical treatment. 6 hours later, the 
physician decided an immediate tracheostomy. After the surgery the child was 
relieved from the respiratory distress for 24 hours then he became dyspnic again. 
The physician carried out a minör procedure that was necessary to relieve the 
child from the dyspnea. Few days later the tracheostomy tube was removed and 
the child discharged from the hospital. 



CASE 21 


Diagnosis & 
reasons 


Acute laryngotracheobronchitis- CROUP (dyspnea relieved by 
tracheostomy placed for a few days only, cough and fever) 
complicated by an obstruction of the tracheostomy tube by 
secretions (relieved after cleaning the tube) 


Explain the 

follovving 

manifestations 


Cough: common with croup due to the presence of tracheal and 
broncjial imflammation and secretions 
Temperature 39.5 C: temperature in croup is varaiable may be 
mild or severe according to the virüs causing the condition 
Observation and medical treatment: the main observation is that 
of the degree of respiratory distress and tacchcyardia to detect 
early heart failure. Medical treat is mainly steroids and 
humidification of respired air, mucolytics and expectorants to 
facilitate getting rid of the secretions in the bronchi and trachea. 
Minör procedure: clearnace of the tracheostomy tube from 
accumulated secretions. 


Further 
examination 
&/or 
investigations 


• Pulse rate 

• Cyanosis 

• Chest x-ray to differentiate from foreign body inhalation 


Treatment 


Steroids 

Mucolytics 

Expectorants 

Antibiotics 

Humidified oxygen inhalation 

Treatment of heart failure 



Case 22: A 45 year old male who is a heavy smoker complained of change in his 
voice of 3 years duration in the form of hoarseness. During the last 3 months his 
voice became very hoarse and he developed mild respiratory distress. Later he 
became severely distressed and required a surgical procedure to relieve the 

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distress. On examination there were bilateral firm non-tender upper neck 
svvellings. 



CASE 22 



Diagnosis & 
reasons 



Leukoplakia of the vocal folds (hoarseness of 3 years duration) 
leading to vocal fold carcinoma (glottic carcinoma increased 
hoarseness, respiratory distress relieved by tracheostomy) with 
bilateral lymph node metastasis (firm non-tender upper neck 
svvellings) 



Explain the 

following 

manifestations 



Hoarseness: the presence of lesions whether leukoplakia or 

carcinoma on the vocal fold will limit its vibration capability 

causing hoarseness 

Bilateral firm non-tender svvellings in the upper neck: lymph 

node metastasis not common vvith vocal fold carcinoma but may 

occur vvhen the tumor spreads to the neighboring supraglottis or 

subglottis 

Surgical procedure: tracheostomy to bypass the glottic lesion 

causing respiratory obstruction 



Further 
examination 
&/or 
investigations 



Other symptoms: cough and hemoptsys 

Indirect laryngoscopy: visualize the lesion and vocal fold 

paralysis 

Laryngeal stroboscopy: to examine the vocal fold 

movement very useful vvith small vocal fold carcinoma 

lesions 

Direct laryngoscopy and biopsy 

CT scan and MRI 

Chest X-ray 



Treatment 



Laser excision of the lesion 

Laryngofissure and cordectomy 

Laryngectomy ( partial or total) 

Radiotherapy for small cordal lesions 

Chemotherapy and palliative treatment for terminal cases 



Case 23: A 40 year old female had repeated attacks of chest infection not 
improving by medical treatment. The patient vvas admitted for investigation of her 
condition in a hospital. A chest x-ray revealed basal lung infection. During her 
hospital stay it vvas noticed that she suffered from chest tightness and choking 
follovving meals. The vvard nurse noticed that the patient refuses fluid diet and 
prefers solid bulky food. 



CASE 23 



Diagnosis & 
reasons 



Cardiac achalasia (basal chest infection due to aspiration, 
choking follovving meals and dysphagia more to fluids) 



Explain the 

follovving 

manifestations 



Chest infection not improving by medical treatment: because of 

continuous aspiration the original condition of cardiac achalasia 

must be treated first and the chest infection vvill improve 

subsequently 

Basal lung infection by X-ray: vvith aspiration by gravity the basal 

lung is alvvays affected 

Patient refuses fluid diet and prefers solid food: solid food 

creates a better stimulation by rubbing against the esophageal 

vvall and so the cardiac sphincter opens vvhile fluids need to 

accumulate in the esophagus before causing a sufficient 

stimulus 

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Further 
examination 
&/or 
investigations 


• X-ray barium swallow esophagus shows a large dilatation 
of the esophagus and a stenosis at the level of the cardiac 
sphincter 

• Esophagoscope 

• CT scan with barium swallow 




• Chest X-ray 


Treatment 


Heller's operation 
Esophagoscopic dilatation 



Case 24: A 4 year old child was referred to an ENT specialist by a pediatrician 
because of repeated attacks of severe chest infection (three in number) during 
the last month that usually resolved by antibiotics, expectorants and mucolytics, 
but the last attack did not resolve. On examination the lower right lobe of the lung 
showed no air entry and a lot of wheezes ali över the chest by auscultation. A 
chest x-ray revealed an opacified lower right lobe. Temperature 38 C, pulse 
120/min and respiration rate 35/min. 



CASE 24 



Diagnosis & 
reasons 



Foreign body inhalation in the right lung most probably a 
vegetable seed as a peanut (attacks of chest infection, no air 
entry and opacified lower right lobe of the lung, fever 
tachycardia and dyspnea 35/min normal reting respiratory rate in 
a child should not exceed 18/min 



Explain the 

following 

manifestations 



Last attack of chest infection did not resolve: the chemical 
bronchopneumonia caused by the vegetable seed has reached a 
severity that it could not be controlled by the medical treatment 
always suspect a foreign body inhalation in a non-responsive 
chest infection in a child 

VVheezes ali över the chest: although the foreign body is in the 
right lung the site of decreased air entry and an opacified lobe by 
X-ray but the chemical effect of the fatty acids in the vegetable 
seed is ali över the lung causing marked dyspnea and tachypnea 
as well 

Pulse 120/min: respiratory failure is also accompanied by 
tachycardia vvhich might lead to heart failure 



Further 
examination 
&/or 
investigations 



Proper history 
Tracheobronchoscopy 



Treatment 



Tracheobronchoscopy and removal of the foreign body followed 

by 

Antibiotics 

Steroids 

Expectorants 



Case 25: A 3 year old child suddenly complained of a sore throat and enlarged 
left upper deep cervical lymph node. Later he suffered from marked body 
weakness and mild respiratory distress that progressively became severe. 
Oropharyngeal examination revealed a grayish membrane on the left tonsil, soft 
palate and posterior pharyngeal wall. 2 days later he developed nasal regurge. 
His temperature was 38 C and pulse 150/min. 



CASE 25 



Diagnosis & | Diphtheria (sore throat, enlarged upper deep cervical lymph 

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reasons 



node, marked vveakness, respiratory distress, extension of the 
membrane outside the tonsil, low grade fever with marked 
tachycardia) 



Explain the 

following 

manifestations 



Enlarged upper deep cervical lymph node: markedly enlarged 

(Bull's Neck) common in diphtheria in the early stages of the 

disease 

Respiratory distress: could be because of heart failure caused 

by marked toxemia or due to extension of the diphtheritic 

membrane to the larynx 

Grayish membrane: due to tissue necrosis 

Extension of the membrane outside the surface of the tonsil: 

diphtheria is a disease of the mucous membrane not only of the 

tonsil 

Pulse 150/min: toxemia causing heart failure leading to a rapid 

pulse 



Further 
examination 
&/or 
investigations 



Swab from the membrane 
Bacteriological diagnosis 



Treatment 



Start treatment immediately do not wait for a definite 

bacteriological diagnosis 

Antitoxin serum 20,000 - 100,000 units daily until the membrane 

disappears 

Bacteriological swabs until the organism disappears from the 

throat 

Antibiotics 

Treatment of heart failure if present 

Tracheostomy for respiratory distress or even marked heart 

failure to decrease the effort of breathing by decreasing the 

respiratory dead space 

Passive and active immunization of the contacts of the patient 



Case 26: A 45 year old male patient presented to the ENT emergency room with 
severe incapacitating dizziness of 5 days duration. The dizziness was continuous 
with no periods of rest and was accompanied by hearing loss and tinnitus in the 
right ear. He was admitted to hospital and medical treatment was started. The 
patient gave a history of right ear offensive continuous discharge of seven years 
duration. On examination there was right beating nystagmus. Otoscopic 
examination of the right ear showed a marginal attic perforation with a discharge 
rich with epithelial flakes, the edge of the perforation showed granulation tissue. 
The left ear was normal. On the next day the patient's condition became worse 
despite the medical treatment, he developed a mild fever of 38.5 C and the 
nystagmus became directed to the left ear. 2 days later the temperature became 
higher 40 C, the patient became irritable, but later became drowsy. On 

examination at this stage there was marked neck rigidity. 

CASE 26 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma (seven 
years of offensive continuous ear discharge, marginal attic 
perforation with epithelial flakes, edge of the perforation shows 
granualtion tissue) complicated by serous labyrinthitis (severe 
incapacitating dizziness, hearing loss and tinnitus, right beating 
nystagmus) follovved by suppurative labyrinthitis (vvorsening of 



60 



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the condition despite medical treatment, mid fever 38 and left 
beating nystagmus) and finally complicated by meningitis (very 
high fever 40, irritability and drowsiness, marked neck ridgidity) 



Explain the 

following 

manifestations 



Incapacitating dizziness: meaning vertigo due to serous 

labyrinthitis with irritation of the vestibular part of the inner ear 

Hearing loss: due to labyrinthitis is sensorineural hearing loss 

Right beating nystagmus: due to irritation of the vestibular 

endorgan with the slow phase away from the diseased ear and 

the fast phase towards the diseased ear 

Offensive continuous ear discharge: cholesteatoma causes 

continuous ear discharge that is offensive because of the 

presence of anerobic organisms and because of bone 

destruction and erosion 

Nystagmus became directed to the left ear: indicating that 

serous labyrinthitis is now suppurative with destruction of the 

vestibular endorgan 

Drowsy: means a decrease in the level of conciousness that 

vvhich occurs with meningitis and intracranial complications 



Further 
examination 
&/or 
investigations 



CT scan 
Audiogram 
Lumbar puncture 



Treatment 



Treatment of meningitis: antibiotics, lower intracranial tension 
Treatment of cholesteatoma: tympanomastoidectomy 
Labyrinthitis will subside after removing the causing 
cholesteatoma (no need to carry out labyrinthectomy as this wil 
spread more the infection) 



Case 27: The mother of a 3 year old child complained that her child had a fever 5 
days ago. 2 days following that he developed severe right sided earache that kept 
the child continuously crying. A day later she noticed that his mouth was 
deviated to the left side and he was unable to close the right eye. 



CASE 27 


Diagnosis & 
reasons 


Right acute suppurative otitis media (fever of short duration, 
right sided earache) complicated by right lower motor neuron 
facial paralysis (inability to close the right eye and deviation of 
the angle of the mouth to the left) the cause is dehiscence of the 
fallopian canal in the middel ear so the pus under tension of 
acute suppurative otitis media causes inflammation and 
pressure on the facial nerve 


Explain the 

follovving 

manifestations 


Severe right earache: due to psu formation in the suppurative 
phase of acute suppurative otitis media leading to pressure and 
bulging of the tympanic membrane 

Unable to close the right eye: due to lower motor neuron facial 
nerve paralysis leading to paralysis of the orbicularis occuli 
responsible for the firm closure of the eye lids 


Further 
examination 
&/or 
investigations 


• Otoscopic examination: will most probably show a 
congested bulging tympanic membrane 

• Audiogram and tympanogram will show an air bone gap of 
conductive hearing loss and a flat tympanogram type B 

• Culture and antibiotic sensitivity of the ear discharge 
obtained after performing myringotomy 



61 



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Treatment 



Urgent myringotomy to relieve pressure on the facial nerve 
Antibiotics according to culture and antibiotic sensitivity 
Steroids to relieve edema due to inflammation of the facial nerve 
Çare of the eye by drops ointment and closure to prevent 
possible corneal ulceration 



Case 28: A 30 year old female patient developed a sudden attack of fever and 
rigors. She was admitted to the fever hospital and properly investigated and 
received an antibiotic. On the fifth day after her admission a blood culture was 
requested and the result was negative for bacteria. The patient improved and was 
discharged from hospital; but 2 weeks later the condition recurred with a very 
high fever and there was a tender swelling in the right side of the neck. An 
otologic consultation was obtained as the patient mentioned that she had a right 
chronic offensive otorhea for the last 5 years. The otologist found an aural polyp 
with purulent ear discharge. A laboratory workup showed Hb%= 7gm% WBC 

count 23,000/cc. 

CASE 28 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma (chronic 
offensive otorhea of 5 years duration, an aural polyp) 
complcated by lateral sinüs thrombophlebitis (fever and rigors, 
tender lymphadenitis in the right upper deep cervical lymph 
nodes, marked anemia and leucocytosis) 



Explain the 

following 

manifestations 



Fever and rigors: due to spread of infection to the bloodstream 
Negative blood culture: as the patient is receiving antibiotics 
Tender swelling in the right upper neck: could be due to 
lymphadenitis caused by extending thrombophlebitis in the 
internal jugular vein or due to the inflammation of the veins wall 
Aural polyp: an indication of chronic ear inflammation especially 
by cholesteatoma 

Hb% 7gm%: marked anemia as the organism in the blood 
releases hemolysing causing hemolysis of the RBCs - it is one 
of the cardinal signs of thrombophlebitis 



Further 
examination 
&/or 
investigations 



CT scan of the ear 

MRI and MR venography to diagnose thrombophlebitis 

Blood culture after stopping antibiotics for 48 hours 

Bloof film to exlude malaria 

Leucocytic count and hemoglobin to follovv up the case 



Treatment 



Intravenous antibiotics 

Anticoagulants to limit spread of the thrombus 

Tympanomastoidectomy for the cholesteatoma 



Case 29: An 18 year old male patient presented to the ENT clinic with an offensive 
continuous right ear discharge of 2 years duration for which he received 
antibiotic ear drops, but with no improvement of his condition. A month ago a 
swelling appeared behind the right ear. The swelling was red, hot, tender and was 
accompanied by deep seated pain and a fever 39 C . The swelling was incised by 
a surgeon and pus released after which the temperature dropped to 37.5 C but the 
pus continued draining from the incision and the incision did not heal since then. 
CASE 29 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma 
(continuous offensive otorhea, no improvement with antibiotic 
ear drops) complicated by mastoiditis and a mastoid abscess 

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(swelling red hot tender, deep seated pain and fever followed by 
a mastoid fistula (incision made by surgeon, no healing of the 
incision) 


Explain the 

following 

manifestations 


Red hot tender swelling: criteria of an abscess that originated 
from the mastoid diagnostic when it is fluctuant 
İncision did not heal: as the cause of the mastoid abscess is 
mastoiditis in the bone of the mastoid the wound will never heal 
unless the underlying mastoiditis is treated by mastoidectomy to 
clear the bone of the mastoid from the infected bone tissue 


Further • Other criteria of mastoiditis as: sagging of the 
examination posterosuperior extenal auditory canal wall, reservoir 
&/or sign, tenderness ali över the mastoid especially at the tip, 
investigations preservation of the retroauricular sulcus 

• X-ray shows hazziness of the mastoid bone air cells 
indicating an inflammation of the bone partitions between 
the air spaces 

• CT scan to show the underlying cholesteatoma and its 
extensions 

• Audiogram 


Treatment 

ğ 


Tympanomasoidectomy to remove the underlying causative 

cholesteatoma 

Antibiotics 



Case 30: A 35 year old male patient had been complaining of a right continuous 
offensive otorhea for the last 10 years. One month ago he had a very high fever 
and became drowsy. This condition lasted for 5 days, after which the fever 
dropped and the drowsiness disappeared. The patient kept complaining of a mild 
non continuous headache. One week ago the patient felt that he could not go up 
and down the stairs easily. Neurological examination revealed right side body 
weakness in the upper and lower limbs. There was also nystagmus and a 
difficulty on grasping objects by the right hand. Temperature was 36 C, pulse 
80/min. The patient was slightly disoriented to his surrounding and was slow in 
his responses. 



CASE 30 


Diagnosis & 
reasons 


Right chronic suppurative otitis media - cholesteatoma 
(continuous otorhea of 10 years duration) complicated by a 
cerebellar abscess (headache, imbalance, weakness on the same 
side of the body right, nystagmus, difficulty grasping objects by 
the right hand, temperature 36 C, disorientation ans slow 
responses) 


Explain the 

follovving 

manifestations 


Original high fever and drowsiness: encephalitic stage of brain 

abscess 

Mild non-continuous headache: latent quiescent stage of the 

brain abscess 

Could not go up and down the stairs: imbalance and due to 

hypotonia on the right side (same side) of the body 

Difficulty in grasping objects: incoordication of cerebellar attaxia 

Disorientation and slow responses: end stage of brain abscess 

stage of stupor 


Further 

examination 

&/or 


• Examination of cerebellar function: finger nose test, knee 
heel test, dysdidokokinesia 

• CT scan with contrast for the brain and the ear 



63 



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investigations 



MRI 

Fundus examination may show papilledema 

Blood picture especially leucocytic count for follow up and 

prognosis 



Treatment 



Antibiotics that cross the blood brain barrier 

Avoid lumbar puncture as it might lead to conization of the 

medulla oblongata and death 

Drainage of the abscess or excision neurosurgically 

Tympanomastoidectomy for the cholesteatoma 



Case 31 : A 25 year old female is complaining of bilateral nasal obstruction of 5 
years duration. She gave a history of attacks of sneezing, lacrimation and watery 
nasal discharge that may be clear or yellowish green. On examination her nasal 
cavities were blocked by smooth glistening pedunculated nasal masses with a 

clear nasal discharge. 

CASE 31 



Diagnosis & 
reasons 



Nasal allergy (history of sneezing, watery nasal discharge) with 
allergic nasal polypi (smooth glistening pedunculated nasal 
masses) 



Explain the 

following 

manifestations 



Lacrimation: most cases of allergic rhinitis are accompanied by 
conjunctival spring catarrh causing lacrimation 
Yellowish green nasal discharge: may be due to secondary 
bacterial infection or the allergy itself as the dischage is rich in 
eosinophils that give the yellowish green color 
Glistening pedunculated nasal masses: due to the allergy the 
nasal mucosa is edematous and the lining mucosa of the 
sinuses is prolapsed like bags filled with water and hence they 
are pedunculated and glistening - the common sinuses to cause 
this are the ethmoid because of the large surface area of the 
mucosa as they are multiple sinuses 



Further 
examination 
&/or 
investigations 



CT scan to visualize the extent of nasal polypi 
Skin allergy tests 
Radioallergosorbent test RAST 
Serum IgE level 



Treatment 



Remove nasal polypi by endoscopic nasal surgery 

Treatment of allergy by avoidance of the cause of allergy, 

hyposensitization 

Treatment of allergy by medical treatment: steroids, local 

steroids, antihistamines 

Avoid non-steroidal antiinflammatory drugs as aspirin in ali 

forms as it leads to the exacerbation of allergy and leads to the 

formation of nasal polypi (aspirin triade) 



Case 32: A 50 year old male complained of a swelling in the upper right side of 
the neck of 2 months duration. The swelling was firm and non-tender and 
progressively increasing in size. The patient mentioned that he has been 
suffering from right side offensive blood stained nasal discharge of 6 months 
duration. Now he has diplopia, right side nasal obstruction and looseness of the 

teeth of the right side of the upper jaw. 

CASE 32 



Diagnosis & 
reasons 



Right cancer maxilla (right side offensive blood stained nasal 
discharge in a 50 year old) with right upper deep cervical lymph 

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node metastasis (firm non-tender swelling in the right upper 
neck) 


Explain the 

following 

manifestations 


Firm non-tender swelling in the right upper neck: malignant 

lymph node matastasis is firm and usually non-tender but may 

be tender in some cases 

Right side offensive blood stained nasal discharge: due to the 

presence of the malignant tumor in the nasal cavity destroying 

the nasal mucosa with subsequent infection of the necrotic 

tissue 

Diplopia: double vision due to orbital extension by the tumor 

causing proptosis 

Looseness of the teeth of the right upper jaw: due to destruction 

of the roots of the teeth in the alveolus 


Further 
examination 
&/or 
investigations 


• Endoscopic examination of the nose and biopsy 

• CT scan to show the extent of the tumor, metastasis and 
involvement of the big vessels of the neck 

• Ophthalmic examination 

• Dental examination 


Treatment 


Surgical radical maxillectomy to remove the maxilla and the 

metastatic lymph nodes 

Radiotherapy for selected cases 

Chemotherapy 

Palliative management for inoperable cases 



Case 33: A 30 year old female had a common cold 6 weeks ago. This was 
followed by right forehead pain, upper eyelid edema and a temperature of 38.5 C. 
Later her fever rose to 40.5 C, the lid edema increased and she started to 
complain of double vision. On examination the eye showed a downward and 
lateral proptosis. She now presented to the emergency room with decreased level 
of consciousness and marked neck rigidity. 



CASE 33 


Diagnosis & 
reasons 


Common cold complicated by right frontal sinusitis (forehead 
pain, upper eye lid edema and temperature 38.5 C) complicated 
further by subperiosteal orbital abscess (high fever 40.5 C, 
increased lid edema, proptosis) finally complicated by meningitis 
(marked neck ridgidity and decreased level of consiousness) 


Explain the 

follovving 

manifestations 


Right forhead pain: due to acute suppurative frontal sinusitis 
with inflammation of the mucosal lining of the frontal sinüs 
Downward and lateral proptosis: due to the formation of a 
subperiosteal orbital abscess in the upper medial corner of the 
orbital cavity which displaces the globe from its position and 
leadsto diplopia 
Neck ridgidity: due to inflammation of the meninges 


Further 
examination 
&/or 
investigations 


• Endoscopic nasal examination 

• CT scan with contrast 

• Ophthalmic examination with fundus examination 

• Lumbar puncture 


Treatment 


Antibiotics that cross the blood brain barrier 

Surgical drainage of the subperiosteal orbital abscess either 

through the orbit or through the nose by the nasal endoscope 

Treatment of the underlying frontal sinusitis to prevent 

recurrence 



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Case 34: A 25 year old farmer has been complaining of nasal obstruction, 
greenish nasal discharge and nasal deformity of one year duration. On 
examination the nose was broad and contained a lobulated firm mass that may 
bleed on touch. Also, there was a hard swelling below the medial canthus of the 
right eye. One week ago, he noticed a change in his voice that was followed by 
respiratory distress. On examination there was marked stridor and laryngeal 

examination showed a subglottic laryngeal web. 

CASE 34 



Diagnosis & 
reasons 



Rhinoscaleroma (greenish nasal dischage, nasal deformity, 
broad nose, lobulated firm mass that may bleed on touch) with 
dacrscleroma of the lacrimal sac (hard swelling below the medial 
canthus of the right eye) with laryngoscleroma (change of voice, 
respiratory distress, stridor, subglottic web) 



Explain the 

following 

manifestations 




Greenish nasal dischage: characteristic of the infection caused 
by the Klebsiella rhinoscleromatis 

Nasal deformity: due to the fibrosis that accompanies scleroma 
Hard swelling below the medial canthus of the right eye: due to 
involvement of the right lacrimal sac by the scleroma tissue 
which is fibrous and hard the swelling may be cystic and 
fluctuant in other situations when there is only a nasolacrimal 
duct obstruction without involvement of the sac with the 
scleroma tissue 

Subglottic laryngeal web: scleroma when involving the larynx is 
commonly in the subglottic region as it is an extension of 
trahceal scleroma this web is the cause of respiratory distress 
and stridor 



Further 
examination 
&/or 
investigations 



Endoscopic nasal examination and biopsy that wil show 
Mickulicz celi, Russel body and othe chronic inflammatory 
cells especially the active celi in scleroma the fibroblast 
CT scan of the nose 

CT scan of the larynx and trachea to assess the degree of 
the subglottic stenosis 



Treatment 



Medical treatment with Rifampscin 

Surgical treatment in the form of tracheostomy to relieve 

respiratory obstruction 

Laser excision of the subglottic web 

Removal of the mass in the lacrimal sac and 

dacrocystorhinostomy 



Case 35: Following a common cold a 30 year old male started to complain of left 
forehead pain and edema of the upper eyelid. One week later, his general 
condition became worse, there was a fever 40 C and rigors. On examination there 
was right eye proptosis with conjunctival chemosis and paralysis of eye 
movement. Also, there was a small red, hot tender swelling in the vestibule of the 

right nasal cavity. 

CASE 35 



Diagnosis & 
reasons 



Common cold caused two conditions first left frontal sinusitis 
(left forehead pain, edema of the left upper eye lid) second right 
nasal furuncle (small red hot tender swelling in the right nasal 
vestibule) the second condition is complicated by cavernous 
sinüs thrombosis (fever 40 C and rigors, right eye proptosis, 



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conjunctival chemosis, and paralysis of eye movement) 


Explain the 

following 

manifestations 


Fever 40 C and rigors: spread of infection to the blood in the 

cavernous sinüs causes high fever and rigors 

Proptosis: thrombosis of the retrobulbar veins leads to 

retrorbital edema that pushes the eye forwards 

Conjunctival chemosis: which means edema and congestion of 

the conjunctive due to occlusion of the venous drainage 

Paralysis of eye movement: due to affect of the 3, 4, 6 cranial 

nerves related to the cavernous sinüs 

Swelling in the nasal vestibule: furuncle always occurs in 

relation to a hair follicle or sebaceous gland those are present in 

the nasal vestibule as it is lined by skin 


Further 
examination 
&/or 
investigations 


• Fundus examination 

• CT scan of the nose 

• Blood picture (leusocytic count) 

• Blood culture 


Treatment 


Intravenous antibiotics 

Anticoagulants 

Treatment of the underlying cause furuncle by antibiotic 

ointment and drainage as it has already caused cavernous sinüs 

thrombosis so there is no fear of such a complication 

Treatment of frontal sinusitis 



Case 36: A 40 year old male presented to the ENT clinic with a swelling in the 
right upper neck of 2 months duration. The swelling was non-tender, firm and 
progressively increased in size. After a complete ENT examination there was a 
right conductive hearing loss and a retracted tympanic membrane. Also, there 
was right vocal fold paralysis and on swallowing there was also some nasal 
regurge. The patient gave a history of an offensive sanguineous post nasal 
discharge. 



CASE 36 


Diagnosis & 
reasons 


Nasopharyngeal carcinoma with right upper deep cervical lymph 
node metastasis (early presentation by right upper deep cervical 
lymph node metastasis, right conductive hearing loss, right 
retracted tympanic membrane, offensive sanguineous post nasal 
discharge) 


Explain the 

follovving 

manifestations 


Right conductive hearing loss and retracted tympanic 
membrane: due to nasopharyngeal carcinoma destroying the 
nasopharyngeal orifice of the eustachian tube causing poor 
aeration of the middle ear causing otitis media with effusion 
Right vocal fold paralysis: due to involvement of the vagus nerve 
by the nasopharyngeal carcinoma as the nerve passes just 
lateral the nasopharyngeal wall 

Nasal regurge: paralysis of the vagus high up in the neck close 
to the skull base leads to paralysis of its pharyngeal branch that 
supplies the palate this palatal paralysis causes nasal regurge 


Further 
examination 
&/or 
investigations 


• CT scan to see the extent of the malignancy and lymph 
node metastasis 

• Nasopharyngoscopy and biopsy 

• Audiogram and tympanogram 


Treatment 


Radiotherapy for the primary tumor and the metastsis 

Radical neck dissection for the residual metastatic lymph nodes 



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af ter radiotherapy 

Myringotomy and T-tube insertion of the right tympanic 

membrane to relieve otitis media with effusion 



Case 37: A 50 year old female has been complaining of dysphagia for 3 years. The 
dysphagia was towards solids and stationary in nature. 2 months ago the 
dysphagia progressed to become absolute, there was a change of voice and 
some respiratory distress. On examination there was a firm swelling in the neck 
that was not tender. 



CASE 37 


Diagnosis & 
reasons 


Plummer Vinson disease (dyspahgia towards solids stationary in 
nature for 3 years) complicated by hypopharyngeal carcinoma 
(progression of dysphagia in the last two months to become 
absolute) with lymph node metastasis (firm non-tender swelling 
in the neck) 


Explain the 

follovving 

manifestations 


Dysphagia of 3 years duration: due to Plummer Vinson disease 

that causes inflammation and fibrosis of the hypopharyngeal and 

esophageal walls leading to the formation of webs that cause 

dysphagia 

Progression of dysphagia: Plummer Vinson disease is 

premalignant progression of dysphagia means development of 

malignancy 

Change of voice and respiratory distress: means involvement of 

the larynx or the recurrent laryngeal nerves by the malignancy 


Further 
examination 
&/or 
investigations 


• Indirect laryngoscopy: froth in the region of the 
hypopharynx, a mass may be seen in the post cricoid, 
posterior pharyngeal wall or the pyriform fossa and may 
be laryngeal involvement 

• Direct hypopharyngoscopy and biopsy 

• CT scan 

• Barium swallow 

• General investigation for the patients condition 


Treatment 


Total laryngopharyngectomy if the patient's general condition 

permits with radical neck dissection for the lymph node 

metastasis 

Radiotherapy for inoperable cases 

Chemotherapy 

Palliative treatment for terminal cases 



Case 38: A 25 year old male presented to the ENT emergency room with severe 
right side throat pain, inability to swallow, accompanied by right earache of 2 
days duration. The patient was unable to öpen his mouth and was feverish 40 C. 
On examination there was a tender swelling at the angle of the mandible. The 

patient gave a history of sore throat and fever 39 C during the last week. 

CASE 38 



Diagnosis & 
reasons 



Acute tonsillitis (history of sore throat and fever) complicated by 
right peritonsillar abscess - quinzy (right sided throat pain, 
inability to swallow and to öpen the mouth, fever 40 C) 



Explain the 

follovving 

manifestations 



Right sided throat pain: due to the collection of pus in the 
peritonsillar pain that causes immense throbbing pain 
İnability to swallow: marked dysphagia accompanying the quinzy 
that may lead to drooling of saliva from the mouth 

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Right earache: refered pain along the glossopharyngeal nerve 

(Jackobsen's nerve) 

Unable to öpen the mouth: trismus caused by spasm of the 

medial pterygoid muscle present lateral to the peritonsillar 

abscess 

Tender swelling at the angle of the mandible: inflammed 

jugulodigastric lymphadenitis 


Further 
examination 
&/or 
investigations 


• Complete blood picture with leucocytic count 


Treatment 


Drainage of the quinzy 

Antibiotic therapy for the quinzy and acute tonsillitis 

Tonsillectomy after 2-3 weeks is an absolute indication 



Case 39: A 3 year old child suddenly developed respiratory distress fever 38 C 
and biphasic stridor. İn the ENT emergency room an immediate surgical 
procedure was done after which there was complete relief of the respiratory 
distress and the child received the necessary medical treatment. On the next 
morning the respiratory distress recurred and the attending physician carried out 
an immediate minör interference that relieved the distress immediately. 2 days 
later the child was discharged from hospital in a healthy condition. 



CASE 39 



Diagnosis & 
reasons 



Acute laryngitis (respiratory distress, biphasic sridor, fever, 
complete relief by tracheostomy) 



Explain the 

following 

manifestations 



Biphasic stridor: means stridor in both inspiration and expiration 

caused by lesions in the larynx and the trachea if the condition is 

accompanied by cough it is acute laryngotracheobronchitis - 

croup 

Surgical procedure: is tracheostomy to relieve the respiratory 

distress 

Necessary medical treatment: in such a condition it is mainly 

steroids to relive the laryngeal edema 

Recurrence of respiratory distress after tracheostomy: due to 

tube obstruction by viscid secretions 



Further 
examination 
&/or 
investigations 



Close observation of the patient 
Examine the heart condition as respiratory distress in 
children is commonly accompanied by heart failure 
Chest X-ray 



Treatment 



Close observation of the patient in intensive çare unit 

Oxygenation by humidified oxygen 

Steroids 

Mucolytics 

Antibiotics to prevent secondary infection 



Case 40: A 60 year old heavy smoker has been complaining of hoarseness of 
voice for 3 years. Lately he noticed worsening of his voice and a mild respiratory 
distress on exertion. There was also cough and some blood tinged sputum. On 
laryngeal examination a whitish irregular mass was found on the right vocal fold 
that was found also paralysed. 



CASE 40 



Diagnosis & | Right glottic (laryngeal) carcinoma (hoarseness of voice that is 

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reasons 



worse, mild respiratory distress, cough and blood tinged 
sputum, whitish irregular mass and the vocal fold is paralysed) 
the condition followed the original precancerous condition of 
leucoplakia (hoarseness of voice of 3 years duration in a heavy 
smoker) 



Explain the 

following 

manifestations 



Mild respiratory distress on exertion: due to the presence of the 
glottic cancer that may cause narrowing of the laryngeal lumen 
Blood tinged sputum: carcinoma of the vocal fold may lead to 
destruction of the fine blood vessels on the vocal fold leading to 
some bleeding 

VVhitish irreguar mass: white because of hyperkeratosis of the 
non keratinized vocal fold epithelium due to malignancy irregular 
because of the fungating mass 

Vocal fold paralysis: indicates spread of the malignant lesion to 
involve either the nerve, muscle supply of the right vocal fold 
that is a deep invasion of the vocal fold, also vocal fold fixation 
may occur if the cricoarytenoid joint is involved 



Further 
examination 
&/or 
investigations 



Direct laryngoscopy and biopsy 

CT scan 

Chest X-ray 

General investigations 



Treatment 



Surgical: total laryngectomy (because ther is a fixed vocal fold) 

achieves very good results 

Radiotherapy 

Palliative treatment if the condition is terminal 



Case 41 : A 70 year old male had loosening of the upper left molar tooth which 
was extracted followed by loosening of the next 2 teeth. Healing was very slow at 
the site of extraction and was attributed to his old age. One month later, the 
patient on blowing his nose noticed left side offensive nasal discharge. He also 
noticed that his left nasal cavity was slightly obstructed. He now presented with a 
swelling of the left upper neck that was explained by his dentist as an 
inflammatory lymph node, but it did not disappear by medical treatment. 



CASE 41 


Diagnosis & 
reasons 


Left cancer maxilla (loosening of teeth, absence of healing at the 
site of tooth extraction, left sided offensive purulent nasal 
discharge) with left upper deep cervical lymph node metastasis 
(swelling of the left upper neck not responding to treatment 


Explain the 

follovving 

manifestations 


Loosening of the upper left molar teeth: due to destruction of the 
roots of the teeth and their blood supply by the malignancy in 
the left maxillary sinüs 

Offensive nasal discharge: due to infection on the necrotic 
malignant tissue 

Left nasal obstruction: because of the extension of the 
malignancy from the maxillary sinüs to the nasal cavity 
Swelling in the left upper neck: lymph node metastasis a 
common presentation in cancer maxilla sometimes it is the first 
presentation as the maxillary sinüs is one of the silent areas of 
the head and neck where the secondary malignant nodes may 
clinically present before the primary site of the tumor 


Further 
examination 


• Nasal endoscopy and biopsy 

• CT scan 



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&/or 
investigations 



• General investigations 



Treatment 



Surgical excision by radical maxillectomy and radical neck 

dissection 

Radiotherapy for inoperable cases 

Chemotherapy for certain tumors 

Palliative treatment for terminal cases 



Case 42: A 60 year old female patient has been complaining of left earache of 3 
months duration. One month ago a swelling appeared in the left side of the neck 
that progressively increased in size. 2 days ago she complained of change of her 
voice together with dysphagia. On indirect laryngoscopy there was froth in the 
region behind the larynx. 



CASE 42 


Diagnosis & 
reasons 


Left pyriform fossa malignancy (left earache, change in voice 
and dysphagia, froth behind the larynx) with lymph node 
metastasis (swelling on the left side of the neck progressively 
increasing in size) 


Explain the 

follovving 

manifestations 


Left earache: due to the presence of a malignant ulcer in the left 

pyriform fossa causing referred earache along the vagus nerve 

(Arnold's nerve) 

Swelling that progressively increased in size: lymph node 

metastasis from the primary tumor the pyriform fossa that is 

considered one of the silent areas of the head and neck that 

present with the secondary metastatic nodes before the clinical 

presentation of the primary tumor 

Dysphagia: due to progression of the tumor to involve the 

postcricoid area and may be the other pyriform fossa leading to 

obstruction of the laryngopharynx dysphagia is more to solids 

and later becomes to ali swallowed food that is an absolute 

dysphagia 

Froth in the region behind the larynx: due to the enlarged tumor 

this froth is saliva that is difficult to swallow and accumulates in 

the hypopharynx behind the larynx 


Further 
examination 
&/or 
investigations 


• Direct laryngoscopy and hypopharyngoscopy and biopsy 

• CT scan 

• Barium swallow 

• Chest X-ray 

• General investigations 


Treatment 


Total laryngopharyngectomy with radical neck dissection 
Radiotherapy for inoperable cases 
Chemotherapy for certain tumors 
Palliative treatment for terminal cases 



Case 43: A 60 year old male patient complained of bilateral hearing loss. The 
patient underwent a minör procedure in an ENT clinic followed immediately by 
return of his hearing. 2 days later he complained of severe pain in both ears more 
on the right side. The pain increased on talking and eating and was slightly 
relieved by analgesics. 2 days later a tender non-fluctuant well circumscribed 
svvelling appeared behind the right auricle. 



CASE 43 



Diagnosis & | Right furunculosis (pain in the right ear, increased on talking and 

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reasons 


eating, tender non-fluctuant swelling behind the right auricle) 


Explain the 

following 

manifestations 


Initial bilateral hearing loss: a common cause that is removed by 

a minör procedure that is ear wash is bilateral ear wax 

Severe pain in both ears: diffuse external otitis caused by the ear 

wash if not carried out under aseptic conditions 

Pain increased on talking and eating: furuncle is present in the 

cartilaginous external auditory canal that moves with 

movements of the jaw and so pain increases 

Tender non-fluctuant well circumscribed behind the right auricle: 

due to lymphadenitis of the postauricular lymph node 


Further 
examination 
&/or 
investigations 


• Audiogram if hearing loss persists 

• İnvestigations for diabetis if furuncle recurrs 


Treatment 


Antibiotics 

Analgesics 

Local antibiotic and hygroscopic agents 

Control of diabetis if present 



Case 44: A 50 year old female has been complaining for 10 years of a right 
forehead headache and intermittent nasal discharge. 2 months ago she noticed a 
swelling above and medial to the right eye. This was followed by double vision. 
When she sought medical advice she noticed that nasal discharge had 
completely stopped. She received medical treatment with no improvement. She 
was admitted to hospital with a very high fever 40 C, neck rigidity and impaired 

level of consciousness and continuous forcible vomiting. Vision is blurred. 

CASE 44 



Diagnosis & 
reasons 



1 



Chronic right frontal sinusitis (right forehead headache, 
intermittent nasal discharge) followed by right frontal 
mucopyocele (swelling above and medial to the right eye, double 
vision) complicated by meningitis (very high fever 40 C, neck 
ridgidity, forcible vomitimg, impaired level of conciousness, 
blurred vision) 



Explain the 

following 

manifestations 



Double vision: the mucopyocele of the right frontal sinüs pushed 
the eye globe outwards downwards and laterally causing 
distortion of the visual axis and diplopia the patient tries to 
correct the visual axis by tilting the head and neck called optical 
torticollis 

Nasal discharge had completely stopped: due to obstruction of 
the duct of the frontal sinüs due to formation of the mucopyocele 
Forcible vomiting: meningitis causes increased intracranial 
tension with pressure on the chemoreceptor trigger zone in the 
brainstem leading to projectile forcible vomiting 
Blurred vision: increased intracranial tension dueto meningitis 
causes papilledema of the optic disc 



Further 
examination 
&/or 
investigations 



Lumbar puncture will show turbid CSF under tension that 

will diagnose meningitis when analysed 

CT scan to diagnose the frontal mucopyocele 

Complete blood picture 



Treatment 



Antibiotics that cross the blood brain barrier 

Brain dehydrating measure as diuretics, mannitol 10% 



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Corticosteroids 

After cure from meningitis excision of the mucopyocele 

surgically through external approach 



Case 45: A 50 year old female underwent surgery to remove a swelling in the neck 
that moved up and down with deglutition. Following surgery she started to 
complain of a very weak voice and choking especially when drinking fluids. 2 
vveeks later the condition improved and a month later she had no symptoms. 



CASE 45 


Diagnosis & 
reasons 


Thyroidectomy (surgery to remove a swelling that moves up and 
down with deglutition) complicated by injury of the recurrent 
laryngeal nerve causing vocal fold paralysis (weak voice, 
choking) followed by compensation from the other healthy vocal 
fold or recovery of the paralyzed vocal fold (improved condition) 


Explain the 

following 

manifestations 

L 


Swelling moved up and down with deglutition: is a thyroid 

swelling as the thyroid gland is attached to the larynx with the 

pretracheal fascia and the larynx moves up and down with 

deglutition 

Choking with fluids: the larynx is the sphincter of the airway 

when the vocal fold is paralysed after injury in surgery some 

fluids during drinking may find their way into the airway causing 

cough with some respiratory distress called choking 

İmproved conditon: is due to the compensation by the other non- 

paralyzed vocal fold that is able to move closer to the paralyzed 

vocal fold and so the larynx is closed during swallowing 


Further 
examination 
&/or 
investigations 


• Indirect laryngoscopy for follow-up 

• Laryngeal electromyography 

• Laryngeal stroboscopy 


Treatment 


Follow up the condition for at least a year- compensation 
usually occurs 

Vocal fold injection by fat or teflon by microlaryngosurgery for 
cases that do not improve 



Case 46: A 10 year old child was taken to the emergency room complaining of left 
frontal headache and a mild orbital swelling. He had a severe common cold a 
week before. On examination he was feverish 38 C with left proptosis and 
decrease in extreme left lateral gaze. No chemosis and visual acuity 6/6 in both 
eyes. The patient was admitted and antibiotics started; WBC count 20,000. On the 
following day, the patient's condition became worse, fever became 39.5 C, the eye 
swelling increased, stili there was no chemosis, visual acuity 6/9 in the left eye 
and there was marked photophobia. 



CASE 46 



Diagnosis & 
reasons 



Common cold complicated by left frontal sinusitis (left frontal 
headache) further complicated by left orbital periosteitis and left 
subperiosteal orbital abscess (mild orbital swelling, fever 38 C, 
left proptosis) finally complicated by orbital cellulitis (worse 
condition, increased eye swelling, fever 39 C) and optic neuritis 
(marked photophobia and drop in visual acuity) 



Explain the 

following 

manifestations 



Decrease in extreme left lateral gaze: due to the subperiosteal 
abscess the eye is pushed outwards, downwards and lateral ly 
against the lateral orbital wall and so eye movement in that 



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direction is hindered by the orbital wall 

No chemosis: means no cavernous sinüs thrombosis 

WBC count 20,000: indicates the presence of suppuration in the 

form of an abscess 

Visual acuity 6/9 and marked photophobia: indicates the start of 

optic neuritis as a complication of orbital cellulitis 


Further 
examination 
&/or 
investigations 


• CT scan 

• Ophthalmic examination 

• Fundus examination 

• Follow up leucocytic count 


Treatment 


Antibiotics 

Analgesics 

Drainage of orbital abscess either through external approach or 

endoscopic endonasal approach 



Case 47: A 65 year old male patient had a swelling polypoid in nature in the left 
nasal cavity, diagnosed by many physicians as a unilateral nasal polyp. He also 
complained of left decreased hearing and tinnitus. One week ago, a very small 
swelling appeared in the neck on the left side. The swelling was not tender and 
firm. 



CASE 47 


Diagnosis & 
reasons 


Nasopharyngeal carcinoma (left decreased hearing and tinnitus, 
polypoid swelling in the nose) with lymph node metastasis (left 
small neck swelling that is non tender and firm) 


Explain the 

follovving 

manifestations 


Polypoid swelling in left nasal cavity: due to nasopharyngeal 
carcinoma the lymphatics draining the nose through the 
nasopharynx are obstructed causing lymphedema in the nasal 
mucosa leading to the formation of a polyp this is a secondary 
lymphatic polyp that if biopsied does not contain malignant 
tissue so in every case with a polypoid swelling in the nose 
especially in an adult must examine the nasopharynx for a 
hidden malignancy 

Decreased hearing and tinnitus: due to eustachian tube 
destruction by the nasopharyngeal carcinoma leading to otitis 
media with effusion 
Non tender firm neck swelling: lymph node metastasis 


Further 
examination 
&/or 
investigations 


• Otologic examination: retracted tympanic membrane and 
fluid behind the drum membrane 

• Nasopharyngoscopy and biopsy 

• CT scan 

• Audiogram and tympanogram 


Treatment 


Radiotherapy for primary nasopharyngeal lesion and metastatic 

lymph nodes 

Radical neck dissection for residual lymph nodes after 

radiotherapy 

Myringotomy and T-tube insertion 

Nasal polypectomy 



Case 48: A 35 year old male patient has been complaining of left continuous 
offensive otorhea that was purulent in nature for the last 10 years. Recently he 
suffered from deep seated pain behind the left eye with diplopia. Ear examination 



74 



revealed a marginal pars flaccida (attic) perforation filled with keratin and 
surrounded by granulations. 



CASE 48 


Diagnosis & 
reasons 


Left chronic suppurative otitis media - cholesteatoma 
(continuous offensive purulent otorhea of 10 years duration, 
marginal attic perforation filled with keratin and surrounded by 
granualtion tissue) complicated by petrous apicitis (diplopia and 
depp seated pain behind the left eye) 


Explain the 

following 

manifestations 


Continuous offensive purulent otorhea: so long as there is a 
cholesteatoma these manifestations are present due to infection 
in the cholesteatoma sac the discharge is offensive because of 
bone necrosis and infection by pseudomonas organism 
Deep seated eye pain: this is a trigeminal neuralgia due to 
affaction of the trigeminal ganglion as it is present in the 
trigeminal fossa on the upper surface of the petrous apex 
Diplopia: due to paralysis of the abducent nerve by the 
inflammation in the petrous apex as the nerve passes through 
Dorello's canal causing paralysis of the lateral rectus muscle 
leading to medial convergent paralytic squint 
(Ear discharge + abducent paralysis + trigeminal pain = 
Gardenigo's triade diagnostic for petrous apicitis) 
Marginal attic perforation: cholesteatoma causes marginal 
perforation as it causes erosion of the tympanic sulcus and the 
perforation is present in the attic as the pars flaccida easily 
retracts causing a cholesteatoma formation 


Further 
examination 
&/or 
investigations 


• CT scan of the petrous apex 

• MRI 

• Audiogram 

• Culture and antibiotic sensitivity of the ear discharge 


Treatment 


Antibiotics 

Removal of cholesteatoma by tympanomastoidectomy 



Case 49: A 16 year old boy was struck in the left temporal region during a motor 
car accident. He was hospitalized for observation because of altered state of 
consciousness that subsequently cleared. On examination of his ears there was a 
serosanguineous otorhea from the left ear. Otologic consultation by a specialist 
was obtained on the third day and additional findings included lateralized Weber 
test to the left ear and Rinne negative test also in the left ear. Under sterile 
conditions ear examination showed a laceration in the posterosuperior wall of the 
external auditory canal with a tympanic membrane perforation. A small amount of 
the serosanguineous fluid was present. Facial nerve function was normal. A few 
days later the patient became feverish 39.8 C, irritable with a change in his level 
of consciousness. 



CASE 49 



Diagnosis & 
reasons 



Longitudinal fracture of the left temporal bone (trauma to the left 
temporal region,bloody ear dischage, conductive hearing loss by 
Weber and Rinne test, perforation of the tympanic membrane, 
laceration of the posterosuperior wall of the external auditory 
canal) with CSF otorhea (serosanguineous aotorhea) 
complicated by meningitis (fever 39.8 C, irritable, change in the 
level of conciousness) 



Explain the 
follovving 



Serosanguineous otorhea: means a clear fluid that is blood 
tinged, this is CSF as the condition is later complicated by 

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manifestations 



meningitis -to prove that it is CSF it increases by straining and 
laboratory tests for levels of glucose and proteins 
Lateralized Weber test to the left and Rinne test negative: means 
bone conduction is better than air conduction and so the patient 
is suffering from conductive hearing loss 
Irritable patient: indicating meningeal inflammation which in its 
early stages is accompanied by some encephalitic inflammation 
leading to irritability 



Further 
examination 
&/or 
investigations 



CT scan temporal bone to delineate the fracture 

Chemical and cellular examination of the fluid coming out 

of the ear 

Lumbar puncture in the stage of meningitis 

Audiogram to evaluate the hearing condition 



Treatment 



Antibiotic that crosses the blood brain barrier for the condition 

of meningitis 

Repeated lumbar puncture for meningitis and to control CSF 

otorhea 

Semisitting position, avoid straining, diuretics to control CSF 

otorhea 

If spontaneous healing and stoppage of CSF otorhea does not 

occur in a period of 3 weeks them surgical intervension to seal 

the region of the CSF leak which most probably will be the 

middle cranial fossa dura at the roof of the middel ear or mastoid 

Tympanoplasty for tympanic membrane perforation and 

ossiculoplasty for disrrupted ossicles in there is no spontaneous 

healing in 2-3 months 



Case 50: A 25 year old male is complaining of intermittent mucopurulent 
discharge from the right ear of 3 years duration. Suddenly 2 weeks ago he 
developed very high fever together with diminution of his ear discharge. One 
week ago he accounted for the appearance of a red, hot, tender and fluctuant 
swelling in the upper neck below the right ear. He received medical treatment with 
no improvement of his condition. 



CASE 50 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - tubotympanic type 
(intermittent mucopurulent ear discharge of 3 years duration) 
complicated by mastoiditis (high fever with diminution of ear 
discharge) followed by a mastoid abscess - von Bezold's infra 
auricular abscess (red hot tender fluctuant swelling below the 
right ear in the neck that does not improve with medical 
treatment) 



Explain the 

following 

manifestations 



İntermittent mucopurulent otorhea: an indication of 

tubotympanic suppurative otitis media where the discharge 

contains mucus and may dry up sometimes 

Very high fever with diminution of ear discharge: Reservoir sign 

an indication of the occurrence of mastoiditis 

Red hot tender fluctuant swelling in the upper neck below the 

right ear: due to escape of pus from the mastoid process along 

the deep surface of the sternomastoid muscle - fluctuant means 

the presence of an abscess cavity 

No improvement of the condition with medical treatment: the 

condition reguires surgical drainage and a mastoidectomy to 



76 



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clear the infection in the mastoid 


Further 
examination 
&/or 
investigations 


• CT scan 

• Complete blood picture especially leucocytic count 

• Audiogram 

• Culture and antibiotic sensitivity test for the ear discharge 


Treatment 


Drainage of the abscess in the neck 

Mastoidectomy to clear the mastoid f rom infection 

Myringotomy if the tympanic membrane perforation is small to 

help draining the middel ear 

Antibiotics following surgery according to culture and sensitivity 

test 

Tympanoplasty at a later stage after infection subsides 



Case 51 : A male patient 54 years old began to experience difficulty in swallowing 
of solid food with a sensation of arrest of food at the root of the neck. 2 months 
later, the difficulty in swallowing included fluids as well. Recently he felt a change 
of voice together with difficulty in breathing. 



CASE 51 


Diagnosis & 
reasons 


Malignancy of the hypopharynx or the esophagus (progressive 
dysphagia, development of change of voice and difficulty in 
breathing) 


Explain the 

follovving 

manifestations 


Sensation of arrest of food in the root of the neck: occurs with 
obstruction of the alimentary tract at the level of the lower 
hypopharynx but commonly with esophageal obstruction 
2 months later difficulty in swallowing included fluids as well: 
indicating a progressive dysphagia of a mechanical obstructive 
nature by a mass lesion that starts towards solids and 
progresses to include fluids later on 

Change of voice accompanied by difficulty in breathing: could be 
due to extension of the tumor to mechanically obstruct the 
airway or due to recurrent laryngeal paralysis bilaterally causing 
laryngeal paralysis and change of voice 


Further 
examination 
&/or 
investigations 


• CT scan of the neck 

• MRI of the neck 

• Barium swallow pharynx and esophagus 

• Hypopahryngoscopy or esophagoscopy and biopsy 

• General investigations to assess general condition of the 
patient 


Treatment 


Surgical excision (total laryngopharyngectomy with 

esophagectomy and stomach pull up operation) 

Radiotherapy 

Chemotherapy 

Pallaitive treatment 



Case 52: A 9 year old child was brought to the emergency having headache and 
vomiting. The attending physician examined him and found neither surgical nor 
medical gastrointestinal causes for such vomiting. Temperature was 38 C and 
blood picture revealed leucocytosis. A neurologist was consulted who 
discovered slowness of speech and weakness in the right upper limb. The 
patient's parents reported that he has been staggering for the last 2 weeks. They 
also reported right offensive ear discharge since early childhood. Otologic 



77 



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examination showed a left retracted tympanic membrane and a right red fleshy 

pedunculated mass with an offensive otorhea. 

CASE 52 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma (right 
offensive ear discharge since early childhood, red fleshy 
pedunculated mass) complicated by right cerebellar abscess 
(weakness of the right upper limb, staggering, headache and 
vomiting) and left otitis media with effusion (left retracted 
tympanic membrane) 



Explain the 

following 

manifestations 




Headache and vomiting with no surgical or gastrointestinal 

cause: the cause is increased intracranial tension due to the 

cerebellar abscess 

Temperature 38 C: usually fever with a brain abscess is not so 

high and maybe subnormal in some instances due to pressure 

on the heat regualting center 

Leucocytosis: is diagnostic for the presence of an abscess 

Slowness of speech: slurred speech occurs in cerebellar attaxia 

due to incoordination of the muscles responsible for speech 

Right upper limb weakness: weakness due to hypotonia in 

cerebellar lesions is on the same side as the pathology in the 

cerebellum namely the abscess 

Staggering: incoordination of the muscles for posture leads to 

staggering and a sensation of vertigo 

Left retracted tympanic membrane: due to an associated otitis 

media with effusion in the left middle ear 

Right fleshy pedunculated mass: an aural polyp occurring with 

the cholesteatoma in the right ear 



Further 
examination 
&/or 
investigations 



Neurologic examination: finger nose test, knee heel test, 

dysdiadokokinesia 

CT scan with contrast to show the cerebellar abscess 

Audiogram and tympanogram 

Follow up leucocytic count 

Fundus examination 

No lumbar puncture as this might lead to brainstem 

conization 



Treatment 



Drainage or excision of the abscess through a neurosurgical 

approach 

Tympanomastoidectomy for cholesteatoma 

Antibiotics that cross the blood brain barrier 

Brain dehydrating measures to lower the increased intracranial 

tension 



Case 53: A laborer fell down from a height and lost consciousness. On 
examination, he was found comatose with bleeding from the right ear. Few days 
later he recovered his consciousness and the bleeding from his ear stopped but 
a clear watery fluid continued pouring from the ear especially on straining. This 
watery otorhea continued for one month during which he developed recurrent 
attacks of fever and headache that recovered with medical treatment and a minör 
procedure. One of these attacks was characterized by rigors and tender enlarged 

right upper deep cervical lymph nodes. 

CASE 53 



Diagnosis & | Longitudinal fracture of the right temporal bone (fail from height, 

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reasons 



bleeding from the right ear) with right CSF otorhea (watery 
otorhea especially with straining) complicated by recurrent 
meningitis (fever, headache recovered with medical treatment 
and minör procedure - lumbar puncture) the last attack is lateral 
sinüs thrombophlebitis (fever rigors and tender enlarged upper 
deep cervical lymph nodes) 



Explain the 

following 

manifestations 



Bleeding from the ear: due to fracture in the external auditory 

canal and torn tympanic membrane 

VVatery otorhea that increased with straining: CSF flow increases 

with straining due to increased CSF pressure with straining 

Minör procedure: is lumbar puncture that causes temporary 

relief of headache in cases of meningitis due to lowering of the 

intracranial tension 

Rigors: infection has reached the blood 

Tender enlarged upper deep cervical lymph nodes: inflammed 

nodes due to inflammed internal jugular vein 



Further 
examination 
&/or 
investigations 

Treatment 



• Blood culture 

• Leucocytic count 

• CT scan 

• Laboratory examination of fluid pouring out of the ear 

• Audiogram 

Intravenous antibiotics 

Anticoagulants 

Surgical sealing of the CSF leak from the ear 

İnternal jugular vein ligation if the lateral sinüs thrombophlebitis 
is not controlled properly by medial treatment 



Case 54: A 25 year old male patient complained of sore throat fever and bilateral 
earache of 3 days duration. He then developed very high fever 40 C, severe left 
earache, inability to öpen the mouth, drooling of saliva and a minimal difficulty in 
respiration. He underwent a minör surgical intervention with relief of ali 
symptoms except the sore throat. 



CASE 54 


Diagnosis & 
reasons 


Acute follicular tonsillitis (sore throat, fever and bilateral 
earache) complicated by left peritonsillar abscess - quinzy (high 
fever 40 C, localized left earache, inability to öpen the mouthand 
drooling of saliva) 


Explain the 

follovving 

manifestations 


Severe left earache: referred along the 9 th cranial nerve - 

glossopharyngeal nerve along its tympanic branch - 

Jackobsen's nerve 

İnability to öpen the mouth: trismus caused by the peritonsillar 

abscess irritating the medial pterygoid muscle that goes into 

spasm 

Drooling of saliva: due to marked dysphagia caused by quinzy 

the patient is unable to swallow his own saliva that pours out of 

his mouth 

Minör surgical intervention with relief of ali symptoms: drainage 

of the quinzy 

Relief of ali symptoms except sore throat: as there is stili acute 

tonsillitis that needs to be treated medically 


Further 
examination 


• Complete blood picture 

• Leucocytic count 



79 



&/or 
investigations 



General investigations in preparation for tonsillectomy 
CT scan or MRI 



Treatment 



Drainage of the quinzy 

Medical treatment for acute tonsillitis 

Tonsillectomy is indicated after 2-3 vveeks 



Case 55: A 60 year old female had a severe attack of epistaxis blood came from 
both nostrils. She received the proper management and the bleeding stopped. 
After removal of the nasal packs, she had severe f rontal headache on the left side 
accompanied by rise in her temperature and a small amount of an offensive nasal 
discharge. 2 days later the temperature became higher 40 C, there was impaired 
consciousness, vomiting, blurring of vision and some neck retraction and 
backache. 



CASE 55 


Diagnosis & 
reasons 


Epistaxis commonly due to hypertension (common cause in 
adults) the packs caused nasal infection (offensive nasal 
discharge) and left acute frontal sinusitis (severe frontal 
headache and rise in temperature) finally complicated by 
meningitis (rise of temperature 40 CJmpaired conciousness, 
vomiting and blurring of vision, neck retraction and backache) 


Explain the 

follovving 

manifestations 


Offensive nasal discharge: any nasal packing must be 

associated with antibiotic therapy to prevent nasal infection 

causing the offensive nasal discharge 

Blurring of vision: increased intracranial tension causing 

papilledema 

İmpaired conciousness: due to increased intracranial tension 

and some encephalitis 

Vomiting: due to increased intracranial tension with pressure on 

the chemoreceptor trigger zone 

Neck retraction and backache: the meninges are inflammed and 

so the patient is unable to stretch the meninges in the vertebral 

column leading to neck retraction and backache 


Further 
examination 
&/or 
investigations 


• Lumbar puncture 

• CT scan 

• Complete blood picture 

• Culture and antibiotic sensitivity test for the offensive 
nasal discharge 


Treatment 


Antibiotics that cross the blood brain barrier 

Lowering the increased intracranial tension by repeated lumbar 

puncture, diuretics, steroids and mannitol 10% 

Surgical drainage of the frontal sinüs either endoscopically or 

directly if the medical treatment fails to control the infection 

Treatment of the underlying cause for epistaxis commonly 

systemic hypertension 



Case 56: A 40 year old female was having an offensive purulent ear discharge 
from the right ear for the last 5 years. Recently, she started to suffer from 
dizziness on sudden change of head position only. This was described as a 
momentary feeling of rotation following head movement. Otologic examination 
revealed a right posterosuperior marginal perforation with a scanty offensive 
discharge. Rinne test positive and Weber centralized. 



CASE 56 



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Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma 
(offensive purulent otorhea for 5 years, right posterosuperior 
marginal perforation with a scanty offensive discharge) 
complicated by a labyrinthine fistula in the lateral canal 
(dizziness, feeling of rotation with head movement) 



Explain the 

following 

manifestations 



Sense of rotation following head movement only: with head 
movement the cholesteatoma in the middel ear moves causing 
pressure on the fistula created in the lateral semicircular canal 
by erosion leading to stimulation of a healty inner ear causing 
this sense of vertigo 

Rinne test positive: means air conduction better than bone 
conduction that is normal as there is no destruction of the inner 
ear and no sensorineural hearing loss, also the cholesteatoma 
bridges the ossicular gap and transmits sound to the oval 
window and so ther is no conductive hearing loss as well that is 
why Weber test is centralized 



Further 
examination 
&/or 
investigations 



Fistula test by creating pressure in the external auditory 

canal (finger pressure or siegle pneumatic otoscope) the 

patient experiences vertigo and clinically nystagmus is 

noticed in his eyes 

CT scan to detect the lateral canal fistula 

Audiogram to verify the tuning fork tests 

Balance tests 



Treatment 



Tympanomastoidectomy to remove cholesteatoma and seal the 
lateral canal fistula 



Case 57: A 7 year old boy was seen by an ophthalmologist for headache that has 
been present for the last few months. Headache was maximum between the eyes. 
However, there was no occular cause for such a headache. The child was referred 
to an ENT specialist who noticed nasal intonation of voice and bilateral nasal 
obstruction. The mother reported that her child snores during his sleep and has 
repeated attacks of chest infection. 



CASE 57 


Diagnosis & 
reasons 


Adenoid enlargement (bilateral nasal obstruction, nasal 
intonation of voice, snoring) 


Explain the 

follovving 

manifestations 


Headache between the eyes: could be because of complicated 
ethmoiditis that causes pain between the eyes or due to the 
hypoxia of the child especially during sleep because of snoring 
Nasal intonation of voice: due to nasal obstruction causing 
rhinolalia clausa in which the letters m is pronounced as b 
Snoring: due to nasal obstruction and so the child is a mouth 
breather during his sleep and this causes vibrations of the soft 
palate and snoring 

Repeated attacks of chest infection: due to nasal obstruction the 
child is a mouth breather and air inspired is not cleaned or 
conditioned by the nose and so causes chest infection, also the 
enlarged adenoid is infected and causes a descending chest 
infection 


Further 
examination 
&/or 
investigations 


• X-ray lateral view skull to show the enlarged adenoid and 
the narrowed or obstructed airway 

• Otoscopic examination, audiogram and tympanogram to 
detect if there is otitis media with effusion 



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General hematological investigations especially for 
bleeding tendancy in preparation for surgery 



Treatment 



Adenoidectomy 



Case 58: A 20 year old female complained of severe sore throat of 20 days 
duration. On examination she showed the presence of ulcers and dirty 
membranous lesions in the oropharynx and the oral cavity. She gave a history of 
having typhoid fever 2 weeks prior to the present condition for which she 
received antibiotic therapy and was stili receiving injections of that antibiotic. 



CASE 58 


Diagnosis & 
reasons 


Agranulocytosis caused by the famous antibiotic used for 
typhoid fever namely chloramphenicol ( sore throat for 20 days, 
ulcers covered by dirty mambranous lesions in the oral cavity 
and the oropharynx) 


Explain the 

follovving 

manifestations 


Sore throat of 20 days duration: agranulocytosis due to a marked 
decrease in the granulocytes caused diminished local oral 
immunity causing a sore throat 

Ulcers with dirty membranous lesions: due to decreased 
immunity in the oral cavity and the oropharynx the pathogens 
(bacteria and fungi) present in these spaces start to attack the 
mucous membrane causing ulcers covered by membranes of 
necrotic mucosa that do not have a hyperemic margin 


Further 
examination 
&/or 
investigations 


• Complete blood picture with total and differential 
leucocytic count 

• Hematological investigation to exclude primary 
agranulocytosis due to other causes as leukemia 

• Follow up hematological analysis 


Treatment 


Stop the antibiotic given immediately 

Patient isolation in a special units in a hospital 

Fresh blood transfusion 

Bone marrow transplantation in rare resistant cases 



Case 59: A 17 year old male complained of severe epistaxis and was packed to 
control bleeding. Finally a posterior nasal pack was applied with difficulty and 
after its removal the bleeding recurred again in a more severe manner. He also 
complained of nasal obstruction more on the right side together with decreased 
hearing in the right ear. One month later he developed proptosis of the right eye 
with no limitation of movement and no affection of vision. There was no swelling 
in the neck. 



CASE 59 



Diagnosis & 
reasons 



Angiofibroma (severe recurrent epistaxis in a 17 year old MALE, 
nasal obstruction on the right side, proptosis) 



Explain the 

follovving 

manifestations 



Recurrent severe epistaxis: the angiofibroma is a highly vascular 
benign tumor that is made up of blood sinusoidal spaces and 
easily bleeds severely 

Decreased hearing in the right ear: the angiofibroma causes 
right eustachian tube obstruction leading to otitis media with 
effusion and subsequently conductive hearing loss 
Proptosis with no limitation of movement and no affection of 
vision: the angiofibroma grows through the inferior orbital 
fissure and pushes the globe outwards vision is not affected as 
it does not damage the optic nerve and ther is no limitation of 

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eye movement as it does not damage the occular muscles or 
nerves as the tumor is benign 

No swelling in the neck: it is a benign tumor that does not cause 
any metastasis 


Further 
examination 
&/or 
investigations 


• CT scan with contrast to show the highly vascular tumor 

• MRI and MRA 

• Angiography 

• Excisional biopsy when the tumor is removed completely 
no punch biopsy should be attempted önce the tumor is 
suspected as this may cause severe bleeding 


Treatment 


Angiographic embolization followed by tumor excision through a 
facial degloving approach or other approaches as the 
transpalatal, transmaxillary or transnasal 



Case 60: A 50 year old male patient suffered from a stroke and was comatose. He 
was admitted to hospital where he was intubated and artificially ventilated. He 
recovered 25 days later and was discharged from hospital. Upon discharge he 
only suffered from right body weakness, a change of his voice and some 

dysphagia. 

CASE 60 



Diagnosis & 
reasons 



Stroke complicated by neurologic hemiparesis causing the right 
body vveakness 



Explain the 

following 

manifestations 



Change of voice and dysphagia: as a part of the righ hemiparesis 
there is also right vocal fold paralysis causing the voice change 
and right pharyngeal and esophageal paralysis causing the 
dysphagia 



Further 
examination 
&/or 
investigations 



• MRI brain 

• CT scan 

• Barium swallow 

» Laryngeal examination 



Treatment 



Follow up 

Rehabilitation of the neurological deficits by phoniatric training 

and physiotherapy 



Case 61 : A 2 year old developed a runny nose. After 2 days there was an inability 
to respire followed by severe respiratory distress. He was admitted to a pediatric 
hospital and received medical treatment and kept under close observation. Then 
2 hours later he became cyanosed and the attending ENT surgeon found it 
necessary to perform a surgical procedure to relieve the respiratory distress. 
Another 2 hours later the distress recurred but was rapidly corrected by a minör 
interference by the pediatric interne. 2 days later the child's condition improved 

remarkably and was discharged from hospital in a healthy condition. 

CASE 61 



Diagnosis & 
reasons 



Acute laryngotracheobronchitis - croup (respiratory distress 
following an atack of common cold runny nose, relief of the 
respiratory distress by tracheostomy, great improvement of the 
condition after two days) 



Explain the 

following 

manifestations 



Runny nose: means a catarrhal discharge that occurs with 
common cold 

Severe respiratory distress: means dyspnea due to subglottic 
edema that occurs in the narrow larynx of a 2 year old child 

causing mechanical obstruction of the airvvay 

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Medical treatment: used in this case is steroids to relieve the 

edema in the larynx 

Surgical procedure to relieve respiratory distress: tracheostomy 

indicated with marked stridor, marked tachycardia, or signs of 

respiratory failure as low oxygen saturation 

Minör interference: the tracheostomy tube is obstructed by 

secretions that wre sucked out using a suction machine 

Improved condition in two days: croup is a viral infection that is 

of short duration if treated properly 



Further 
examination 
&/or 
investigations 



Treatment 



Other symptoms: mild fever, cough 

Check the heart if there is tachycardia this is a sign of 

heart failure 

Laryngeal examination 

Chest X-ray 



Medical treatment: steroids, antibiotics, expectorants and 

mucolytics 

Tracheostomy 

İf recurrent condition check for the presence of congenital 

subglottic stenosis by CT scan or direct laryngoscopy 



Case 62: A 70 year old male suddenly complained of absolute dysphagia. The 
barium swallow requested showed arrest of the barium at the midesophagus. 
Esophagoscopy revealed the presence of a foreign body (piece of meat) that was 
removed and the patient was discharged from hospital after he could swallow 
again. One month later he developed jaundice and was readmitted for 
investigation. During his second hospital stay he started to have attacks of 
hemoptsys. 



CASE 62 



Diagnosis & 
reasons 



Cancer esophagus (common presentation is absolute dysphagia 
in an old patient) 



Explain the 

following 

manifestations 



Arrest of barium at the midesophagus: due to the presence of 
the foreign body on top of the malignant lesion causing 
obstruction of the barium flow 

Jaundice and hemoptsys: means metastasis of the malignancy 
of the esophagus to the liver and the lung 



Further 
examination 
&/or 
investigations 



• Esophagoscopy and removal a foreign body from the 
esophagus must always be followed after removal of the 
foreign body by reintroducing the esophagoscope to 
detect any malignancy and take a biopsy from the 
abnormal tissue causing narrowing of the esophagus 

• CT scan 

• Barium swallow 

• Chest X-ray 

• Hepatic functions 

• General investigations 



Treatment 



Surgical esophagectomy 
Radiotherapy 
Chemotherapy 
Palliative treatment 



84 



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Case 63: A 5 year old boy developed change of his voice that was followed by 
stridor. The stridor was severe enough to necessitate a tracheostomy. 2 years 
later the tracheostomy site was not fit for respiration, another tracheostomy was 
done at a lower level. A reddish tissue that was polypoid in nature filled the 
tracheostomes. The child died a year later when his tracheostomy tube became 
obstructed at home. 



CASE 63 



Diagnosis & 
reasons 



Recurrent respiratory papillomatosis (a resistant condition that 
ocurrs in children leading to hoarseness and respiratory distress 
the condition is famous for recurrence especially at the sites of 
tracheostomies, reddish tissue polypoid in nature) 



Explain the 

following 

manifestations 



Tracheostomy site was not fit for breathing after 2 years: 

because of recurrent papilloma at the tracheostome causing 

obstruction of the airway ^^^ 

Reddish tissue polypoid in nature: these are the papilloma the 

can grow to reach large sizes especially in children 

Died a year later: most probably due to recurrent papilloma at a 

level lower than that of the tracheostomy causing airway 

obstruction 



Further 

examination 

&/or 

investigations 

Treatment 



• Laryngoscopy 

• Chest X-ray 

• Biopsy of pappiloma 

Removal of papilloma by laser microlaryngosurgery 

Antiviral gamma interferon as the condition is caused by human 

papilloma virüs 

Tracheostomy in case of severe respiratory distress 



Case 64: A 40 year old female is complaining of attacks of lacrimation and watery 
nasal discharge accompanied by sneezing. She had a severe attack one spring 
morning that was accompanied by respiratory difficulty and she was admitted to 
hospital. She received the proper treatment and her condition improved. On 
examination she had bilateral nasal obstruction by bluish pedunculated masses 
that were covered by a clear mucous discharge. 



CASE 64 


Diagnosis & 
reasons 


Allergic nasal polypi (history of nasal allergy and the presence of 
bluish pedunculated masses in the nose) 


Explain the 

follovving 

manifestations 


Lacrimation: nasal allergy is usually accompanied by spring 

catarrh of the conjunctiva 

Sneezing: a reflex due to presence of edematous fluid in the 

nasal mucosa and one of the symptoms of nasal allergy and 

occurs in the form attacks with nasal obstruction and a watery 

nasal discharge 

Attack accompanied by respiratory difficulty: the respiratory 

difficulty is due to bronchial asthma a common condition 

associated with allergic nasal polypi as both are a type 1 

hypersensitivity 

Bluish pedunculated bluish masses: these are the nasal polypi 

they are bluish because of venous engorgement by the pressure 

from the edematous fluid in the mucosa 


Further 
examination 


• Laboratory tests for type 1 hypersensitivity: skin tests, 
RAST, serum IgE 



85 



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&/or 
investigations 



CT scan of the nose and the paranasal sinuses to show 

the extent of the nasal polypi 

Nasal endoscopy 

Chest X-ray 



Treatment 



Removal of the nasal polypi by nasal endoscopic surgery and 

ethmoidectomy 

Treatment of allergy by avoiding the cause, hyposensitization, 

local and systemic steroids, antihistamines 

Avoid aspirin and non-steroidal antinflammatory drugs as they 

aggrevate the type I hypersensitivity 



Case 65: Following a meal a female patient aged 31 complained of severe pain in 
the right ear together with localized pain in the right side of the neck during 
swallowing. This pain was relieved by analgesics and local mouth gurgles 
containing a local anesthetic, but the pain reappeared after the effect of the drugs 
was över. 



CASE 65 



Diagnosis & 
reasons 



Swallowed foreign body like a fish bone (meal, pain in the throat 
at a certain fixed site relieved by local anesthetics and 
analgesics) 



Explain the 

following 

manifestations 



Severe pain in the right ear: refeered along the vagus or 
glossopharyngeal nerve according to the site of the foreign body 
to the ear 

Pain relieved by local anesthetics: the local anasthetics 
anesthetize the site of injury by the foreign body and so the pain 
disappears but appears again after the effect of the drugs is över 



Further 
examination 
&/or 
investigations 



X-ray of the neck to locate the foreign body 
Laryngopharyngoscopy 



Treatment 



Pharyngoscopy and removal of the foreign body 



Case 66: A 40 year old male had a tympanoplasty for a chronically discharging 
ear. During the postoperative period he developed severe headache, blurring of 
vision and vomiting. This was accompanied later by loss of balance and 
incoordinated body movements on the side of surgery. His temperature was 37 C, 
no neck rigidity, but his level of consciousness kept deteriorating day after day. 
CASE 66 



Diagnosis & 
reasons 



Chronic suppurative otitis media (chronically discharging ear 
requiring tympanoplasty) complicated by cerebellar abscess 
(headache, vomiting, blurring of vision, loss of balance and 
incoordinated body movements on the same side of the ear) 



Explain the 

following 

manifestations 



Severe headache: due to increased intracranial tension causing 

stretch of the dura 

Blurring of vision: due to increased intracranial tension causing 

papilledema of the optic disc 

Vomiting: due to increased intracranial tension causing pressure 

on the chemoreceptor trigger zone 

Loss of balance: imbalance, vertigo and nystagmus are due to 

affection of the balance centers in the cerebellum 

İncoordinated body movements on the side of ear infection: the 

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cerebellum is responsible for coordination of body movements 
on the same side and abscess will cause cerebellar attaxia 
leading to incoordinated body movements that appear as 
tremors, failure to perform certain tests as finger nose test when 
the eye is closed and failure to perform rapid repititive 
movements - dydiadokinesia 

Temperature 37 C: usually with a brain abscess the temperature 
is normal or even subnormal because of pressure on the heat 
regulating center 

No neck rigidity: ther is no meningeal inflammation 
Deteriorating level of conciousness: this is stupor that occurs in 
the advanced case of a brain abscess due to spread of 
encephalitis 



Further 
examination 
&/or 
investigations 



Clinical neurological examination for cerebellar attaxia 
CT scan with contrast to show the abscess the surgery is 
not the cause of the abscess the abscess was there before 
the surgery but in a latent quiescent phase and after 
surgery renewed infection causes it to present in what is 
called the manifest phase 
MRI 
Audiogram 



Treatment 



Antibiotics that cross the blood brain barrier 

Brain dehydrating measures to lower the increased intracranial 

tension 

Avoid lumbar puncture as this might lead to conization of the 

brainstem and death 

Drainage or excision of the brain cerebellar abscess according 

to its stage whether acute or chronic as determined by the CT 

scan and MRI findings 



Case 67: A 25 year old male complains of right nasal obstruction and right 
tenderness of the cheek of 2 years duration. Lately he developed gagging 
especially on lying on his back together with a purulent post nasal discharge. He 
undervvent surgery and his condition improved but recurred again after one year. 



CASE 67 


Diagnosis & 
reasons 


Right chronic maxillary sinusitis (tenderness of the right cheek 
of 2 years duration) that lead to the formation of an antrochoanal 
polyp (gagging when lying on the back, purulent post nasal 
discharge, condition improved after removal of the polyp, 
possibilty of recurrence with antrochoanal polyps) 


Explain the 

follovving 

manifestations 


Tenderness of the cheek: due to chronic inflammation of the 

maxillary sinüs that might lead to some osteitis of the bony wall 

causing tenderness 

Gagging on lying on the back: the antrochoanal polyp if large 

hangs backwards and may irritate the nasopharyngeal mucosa 

causing gagging 

Purulent post nasal discharge: due to chronic sinusitis causing 

the hypertrophy of the maxillary sinüs mucosa and thus the 

antrochoanal polyp 


Further 

examination 

&/or 


• CT scan paranasal sinüs and nose will show an opaque 
maxillary sinüs, a nasal soft tissue mass and a wide sinüs 
ostium 



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investigations 
Treatment 



• Culture and antibiotic sensitivity of the nasal discharge 
Excision of the antrochoanal polyp by functional endoscopic 
nasal and sinüs surgery 

Treatment of chronic maxillary sinustis until complete cure to 
avoid recurrence 
Follow up CT scan 

Local steroid nasal sprays to minimize tissue reaction and 
hypertrophy of the mucosa and reformation of the antrochoanal 

PO'YP 



Case 68: A 20 year old had a submucous resection operation for a deviated nasal 
septum. The next day he had edema of the eyelids of both eyes. Temperature 38 
C and rigors. 2 days later he developed conjunctival chemosis and blurred vision 

and an inability to see sidevvays. 

CASE 68 



Diagnosis & 
reasons 



Septal surgery complicated by cavernous sinüs thrombosis 
(fever, rigors, conjunctival chemosis, inability to see sidevvays) 



Explain the 

following 

manifestations 




Fever and rigors: indicates that infection has reached the blood 

stream in the cavernous sinüs 

Conjunctival chemosis: edema and congestion of the 

conjunctive due to venous obstruction of the veins draining the 

orbit and conjunctiva 

Bluured vision: due to pupillary paralysis - internal 

ophthalmoplegia paralysis of the occulomotor nerve as it passes 

in the wall of the cavernous sinüs 

İnability to see sidevvays: due to paralysis of the extraoccular 

muscles as their nerves pass in the vvall and lumen of the 

cavernous sinüs - occulomotor, trochlear and abducent nerves 



Further 
examination 
&/or 
investigations 



Complete blood picture to shovv leucocytosis 

Blood culture to identify the organism and test for the 

suitable antibiotic 

Eye examination especially fundus examination if possible 

CT scan vvith contrast 



Treatment 



Intravenous antibiotics 

Anticoagualnts 

Follovv up blood picture to notice improvement of condition if the 

leucocytosis improves 



Case 69: A 16 year old male has been complaining of an offensive continuous ear 
discharge of 4 years duration. Suddenly he developed double vision and face 

ache on the same side as the ear discharge. 

CASE 69 



Diagnosis & 
reasons 



Chronic suppurative otitis media - cholesteatoma (offensive 
continuous discharge of 4 years duration) complicated by 
petrous apicitis (face ache, double vision and discharging ear 
called Gradenigo's triade diagnostic for petrous apicitis) 



Explain the 

follovving 

manifestations 



Offensive continuous ear discharge: cholesteatoma causing 
bone destruction and infection by anerobic organisms 
Double vision: due to paralysis of the abducent nerve as it 
passes through Dorello's canal in proximity of the petrous apex 
Face ache: due to affection of the trigeminal ganglion in the 
cavum trigeminale on the upper anterior surface of the petrous 



j^U\ }\£\ 





apex 


Further 
examination 
&/or 
investigations 


• CT scan with contrast 

• Complete eye examination including fundus to exclude 
other complication as cavernous sinüs thrombosis 

• Complete blood picture 


Treatment 


Treatment of the underlying cholesteatoma by removal by 

tympanomastoidectomy 

Antibiotics 

Rehabilitation of the paralytic lesion in the eye 



Case 70: A 30 year old male had an attack of lef t severe earache and lef t loss of 
hearing together with deviation of the angle of the mouth to the right side and 
failure to close the left eye. 3 days later, a swelling vesicular in nature appeared in 
the left external auditory meatus. The condition subsided 10 months later. 



CASE 70 


Diagnosis & 
reasons 


Left lower motor neuron facial paralysis (deviation of the angle 
of the mouth to the right side and failure to close the left eye) 
due to Herpes Zoster Oticus - Ramsay Hunt Syndrome (severe 
earache, hearing loss, vesicular swelling in the left external 
auditory canal, duration of the illness is 10 months) 


Explain the 

follovving 

manifestations 

J 


Severe earache: before the appearance of the vesicles on the 
dermatome of the cutaneous branch of the facial nerve the virüs 
of herpes zoster that was dormant in the geniculate ganglion 
causes severe inflammation of the facial nerve leading to pain 
and paralysis 

Hearing loss: is a sensorineural hearing loss due to affection of 
the vestibulocochlear nerve as it passes beside the facial nerve 
in the internal auditory canal 

Vesicular swelling: appears in the area of the cutaneous 
dermatome of the facial nerve namely the posterior part of the 
most lateral part of the external auditory canal, the concha and 
parts of the auricle; önce the vesicular erruption appears the 
pain starts to subside 


Further 
examination 
&/or 
investigations 


• İnvestigations of the facial nerve (shirmer test, acoustic 
reflex, topognostic tests, electroneuronography, 
electromyography) 

• CT scan to exclude other causes of facial paralysis 

• Audiogram 

• Viral antibody titre 


Treatment 


Antivirals 

Steroids 

Facial nerve exploration and decompression if the 

electroneuronography shows 90% degeneration of the facial 

nerve fibers within 3 weeks from the onset of paralysis 

Çare of the eye during the paralytic period to prevent 

lagophthalmus (drops, ointment and bandage during sleep) 



Case 71: A 30 year old male patient has been complaining of an offensive 
purulent otorhea of the right ear of 3 years duration. A week ago the discharge 
from the ear became blood stained followed by fever and rigors. 2 days ago the 
patient developed right edema of the eyelids and double vision and severe 



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conjunctival chemosis together with a deviation of the angle of the mouth to the 

left side. On examination a bluish area was found behind the right auricle. 

CASE 71 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma (3 year 
duration of an offensive purulent otorhea) complicated by lateral 
sinüs thrombophlebitis (fever, rigors, blood stained ear 
discharge) further complicated by cavernous sinüs thrombosis 
(edema of the right eye lids, double vision and severe 
conjunctival chemosis) and another complication of the 
cholesteatoma is right lower motor neuron facial paralysis 
deviation of the angle of the mouth to the left side) 



Explain the 

following 

manifestations 



Further 
examination 
&/or 
investigations 



Blood stained ear discharge: is an indication that the 

cholesteatoma has eroded the bony walls of the middle ear and 

mastoid and is approaching a vascular structure as the lateral 

sinüs 

Fever and rigors: is an indication that the infection has reached 

the blood stream to due thrombophlebitis of the lateral sinüs 

Edema of the eye lids: due to thrombosis in the retrobulbar veins 

as a consequence of cavernous sinüs thrombosis 

Double vision: diplopia is due to affection of the cranial nerves 

responsible for eye movement present in the wall and lumen of 

the cavernous sinüs 

Severe conjunctival chemosis: due to thrombosis in the 

cavernous sinüs that prevents proper drainage of the ophthalmic 

veins - the cavernous sinüs is affected due to extension of the 

thrombus from the lateral sinüs via the superior petrosal sinüs 

Deviation of the angle of the mouth to the left side: is due to 

lower motor neuron facial nerve paralysis caused by the original 

pathology the cholesteatoma 

Bluish area found behind the right auricle: due to extension of 

the lateral sinüs thrombus to the retroauricular veins via the 

mastoid emissary vein the sign is called Greissenger's sign 

• Complete blood picture to show leucocytosis and marked 
anemia 

• Blood culture 

• CT scan for cholesteatoma 

• İnvestigations for facial nerve paralysis (shirmer's test, 
topognostic tests, electroneuronography) 

• Audiogram 

• Complete eye examination especially fundus examination 
may show engorged retinal veins 



Treatment 



Tympanomastoidectomy for the cholesteatoma 

Management of the lateral sinüs thrombophlebitis surgically 

according to the operative findings 

Intravenous antibiotics 

Anticoagulants 

Steroids for the facial nerve paralysis 

Çare of the eye 



Case 72: A 4 year old child experienced marked loss of weight due to dysphagia 
together with choking during feeding after a house accident that occurred 18 
months ago. The child was admitted to hospital for investigation. The barium 

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swallow showed a very long esophageal stricture in the middle and lower thirds 
of the esophagus. 



CASE 72 


Diagnosis & 
reasons 


Post corrosive esophageal stricture (accident, loss of vveight, 
dysphagia, long esophageal stricture by barium swallow) 


Explain the 

follovving 

manifestations 


Marked weight loss: the child is unable to feed due to the 

esophageal stricture and so loses weight and is unable to grow 

properly 

Choking: is an indication that the stricture is very narrow 

preventing food from passing down and so it accumulates above 

the stricture and may spill över into the larynx and the trachea 

causing choking (cough with some respiratory distress) 

Very long esophageal stricture in the middle and lower thirds of 

the esophagus: common site for the corrosive to cause injury of 

the esophageal wall as it accumulates by gravity in the lower 

parts of the esophagus 


Further 
examination 
&/or 
investigations 


• Diagnostic esophagoscopy 

• General investigations 


Treatment 


Esophagoscopy and dilatation of the esophagus 

Colon by pass operation 

Gastrostomy 



Case 73: A 30 year old laborer who is a heavy smoker has chronic cough and 
expectoration of two years duration. Sputum is yellowish and huge in amount. 
The patient developed attacks of fever and sweating by night, he also lost some 
weight. One month ago, the patient developed a flexion of the neck deformity, 
severe painful dysphagia and a swelling in the neck on the right side that was 
cross fluctuating with another oropharyngeal svvelling. 



CASE 73 


Diagnosis & 
reasons 


Pulmonary tuberculosis (chronic cough and expectoration of 
large amount of yellovvish sputum of two years duration, night 
fever and svveats, loos of vveight) complicated by cervical spine 
tuberculosis - Pott's disease (flexion deformity of the neck) that 
lead to a retropharyngeal cold abscess (painful dysphagia, right 
sided neck svvelling that cross fluctuates vvith an oropharyngeal 
svvelling) 


Explain the 

follovving 

manifestations 


Night fever and svveats: tuberculous signs of prostration 

Flexion of the neck deformity: cervical spine tuberculosis leads 

to destruction of the bodies of the cervical vertebrae causing 

kyphosis 

Severe painful dysphagia: tuberculosis causes marked throat 

pain and painful dysphagia - odynophagia 

Svvelling in the neck that cross fluctuates vvith another 

oropharyngeal svvelling: cold tuberculous chronic 

retropharyngeal abscess the oropharyngeal svvelling crosses the 

midline as it is present behind the prevertebral fascia 


Further 
examination 
&/or 
investigations 


• İnvestigations for tuberculosis: tuberculin test, aspiration 
of caseous material from the cold abscess 

• Chest X-ray 

• CT scan neck and vertebral column 



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• Barium swallow 

Antituberculous drugs 
Excision of the cold abscess 
Correction of cervical spine deformity 



Case 74: A 2 year old male child suffered from marked difficulty in swallowing, 
drooling of saliva of 48 hours duration followed by severe respiratory distress. 
On examination he was very toxic, feverish 40 C with a flexed neck and neck 
muscle spasm. Oropharyngeal examination showed a congested large swelling 
behind the right tonsil and not crossing the pharyngeal midline. 



CASE 74 



Diagnosis & 
reasons 



Acute retropharyngeal abscess (marked dysphagia, drooling of 
saliva, fever 40 C, toxic, flexed neck, congested large swelling 
behind the right tonsil not crossing the pharyngeal midline) 



Explain the 

following 

manifestations 



Marked difficulty in swallowing: marked dysphagia is due to the 
presence of the abscess behind the pharyngeal wall causing 
pain during swallowing with some pharyngeal obstruction 
Drooling of saliva: dysphagia is up to the extent that the child 
can not swallow his saliva and it drips from his mouth 
Severe respiratory distress: the edema in the pharynx may 
extend to involve the larynx causing respiratory distress that 
may necessitate a tracheostomy 

Flexed neck: the child places his head and neck in a flexion 
position in order to minimize the throat pain 
Swelling not crossing the midline: the abscess is due to 
suppuration in the retropharyngeal lymph node of Henle present 
between the buccopharyngeal fascia and the prevertebral fascia, 
the median pharyngeal raphe attaches these fascia preventing 
the abscess from crossing the midline 



Further 
examination 
&/or 
investigations 



Complete blood picture to show leucocytosis 
X-ray lateral view neck 
CT scan neck with contrast 



Treatment Tracheostomy in case of respiratory distress 

Drainage of the abscess through a transoral longitudinal incision 

in the posterior pharyngeal wall 

Antibiotics 

Analgesics 

Parentral nutrition or ryle tube feeding 

Case 75: A 30 year old male boxer after a boxing match developed right side 
watery nasal discharge intermittent in character. 2 days following the match he 
was taken to hospital with impaired consciousness fever 40 C and vomiting that 
did not improve by any antiemetics. His level of consciousness deteriorated and 
he passed away that night. 



CASE 75 



Diagnosis & 
reasons 



Traumatic CSF rhinorhea (boxing, unilateral watery nasal 
intermittent discharge) complicated by meningitis (impaired 
conciousness, fever 40 C, vomiting, deterioration and death) 



Explain the 

following 

manifestations 



VVatery intermittent nasal discharge: following trauma a nasal 
discharge that is watery and increase with straining 
İmpaired conciousness: due to encephalitis accompanying 



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meningitis 

Fever 40 C: due to meningeal inflammation 

Vomiting: due to increased intracranial tension 



Further 
examination 
&/or 
investigations 



Other manifestations of meningitis: neck rigidity, Kernig's 

sign, Brudzinski's sign 

Fundus examination 

Lumbar puncture to prove meningitis and identify the 

organism 

CT scan for the site of trauma 

Laboratory tests for the watery nasal discharge to prove 

that it is CSF (glucose, protein, chloride) 

Lumbar puncture with metrizimide injection to show the 

site of the CSF leak in the nose 



Treatment 



Antibiotics that cross the blood brain barrier 
Lowering of the increased intracranial tension 
Correction of the fracture in the anterior cranial fossa and 
stopping the CSF leak from the nose 



Case 76: A 12 year old child had an attack of fever and right ear earache of 3 days 
duration followed by right ear discharge and relief of the earache but the fever 
persisted. He received no medical treatment. Ten days later the discharge 
decreased in amount and the fever was elevated. Later a fluctuant red hot and 
tender swelling appeared behind the right auricle with preservation of the 
retroauricular sulcus. Later the swelling released spontaneously a large amount 
of pus. 



CASE 76 



Diagnosis & 
reasons 



Right acute suppurative otitis media (fever, earache of 3 days 
duration followed by ear discharge) complicated by mastoiditis 
(persistence and elevation of the fever and a continuous 
discharge) further complicated by a retroauricular mastoid 
abscess (fluctuant red hot tender swelling behind the right 
auricle with preservation of the retroauricular sulcus) later with 
the formation of a mastoid fistula (swelling spontaneously 
released a large amount of pus) 



Explain the 

following 

manifestations 



Ear discharge and relief of earache: as the discharge passes out 
of the ear through a tympanic membrane perforation the pain 
decreases 

Decrease of ear discharge and persistence of fever: Reservoir 
sign an indication for the development of mastoiditis 
Preservation of the retroauricular sulcus: in case of mastoiditis 
the edema due to the bone inflammation is subperiosteal 
elevating the periosteum covering the mastoid process and so 
the retroauricular sulcus is preserved in case of a subcutaneous 
inflammation the inflammatory edema extends into the sulcus 
and obliterates it 

Spontaneous release of a large amount of pus: means 
occurrence of a mastoid fistula 



Further 
examination 
&/or 
investigations 



X-ray mastoid shows a hazy mastoid appearance 

CT scan to show inflammation of the mastoid process and 

to show a possible underlying pathology as a congenital 

cholesteatoma 

Audiogram 

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Treatment 



• Culture and antibiotic sensitivity test of the ear discharge 
Mastoidectomy 
Myringotomy 
Medical treatment as antibiotics 



Case 77: The mother of a six month old infant complained that her infant had a 
high fever 40 C, screaming attacks, convulsions followed by rolling of the head 
sideways. This was followed 5 days later by drovvsiness, inability to feed and 

some diarrhea and neck retraction. 

CASE 77 



Diagnosis & 
reasons 



Acute suppurative otitis media (high fever 40 C, screaming due 
to pain) complicated by meningitis (drowziness, neck retraction) 



Explain the 

following 

manifestations 




Screaming attacks: infants are unable to localize pain to the ear 

so pain is presented by screaming 

Convulsions: may be due to the high fever 40 C 

Rolling of the head sideways: is an indication that pain is from 

the ears as the child tries to push the painful ears against his 

pillovv 

İnability to feed and diarrhea: due to passage of some pus 

through the wide eustachian tube of a child this pus irritates the 

stomach and the intestine causing gastroenteritis 

Neck retraction: indicating meningitis a common complication 

for acute suppurative otitis media in this age group because the 

sutures of the skull between the middle ear and the intracranial 

cavity are stili öpen and can transmit infection and also the 

tympanic membrane is stili thick and does not easily perforate 



Further 
examination 
&/or 
investigations 



Otoscopic examination may show a congested bulging 

tympanic membrane with loss of lutre 

Neurologic examination (kernig's sign and Brudzinski's 

test) 

Fundus examination may show pailledema 

Lumbar puncture 

Culture and antibiotic sensitivity of the ear discharge 



Treatment 



Antibiotics that cross the blood brain barrier 

Brain dehydrating measures as diuretics and mannitol 10% in 

the proper dose 

Urgent myringotomy to drain the middle ear 



Case 78: A 30 year old male came to the outpatient ENT clinic complaining of 
torticollis to the left side. On examination, the neck was slightly rigid with severe 
tenderness on the left side of the neck. He was admitted for investigation of his 
condition, 2 hours after admission he had an attack of fever accompanied by 
rigors that was not relieved by antipyretics. The patient gave a history of foul 
smelling left ear discharge of 7 years duration that was associated with hearing 

loss. Ear examination shovved an aural polyp and a purulent discharge. 

CASE 78 



Diagnosis & 
reasons 



Left chronic suppurative otitis media - cholesteatoma (foul 
smelling ear discharge of 7 years duration, aural polyp and 
purulent discharge on examination) complicated by lateral sinüs 
thrombophlebitis (fever and rigors) with extension of the 
thrombus to the left internal jugular vein (left sided torticollis 
meaning bending of the neck to the left side, tenderness in the 

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left side of the neck) 



Explain the 

following 

manifestations 



Torticollis: bending of the neck to the left side to minimize the 

pain in the left jugular vein due to thrombophlebitis 

Fever and rigors: indicates spread of infection to the blood 

stream 

Aural polyp: is an inflammatory reaction to severe otitis media 

especially with cholesteatoma 



Further 
examination 
&/or 
investigations 



Complete blood picture 

Blood culture 

CT scan 

Audiogram 



Treatment 



Intravenous antibiotics 

Anticoagulants 

Tympanomastoidectomy for cholesteatoma after improvement of 

the general condition of the patient 

Possibly ligation of the internal jugular vein to avoid showers of 

septic emboli that might cause fever and rigors and later 

septicemia and pyemia 



Case 79: A 27 year old male has been complaining of a right purulent otorhea of 7 
years duration. Suddenly he developed attacks of loss of balance and severe 
sense of rotation. This was followed after 5 days by complete relief of the 
condition but accompanied by a complete hearing loss in the right ear. Weber 
tuning fork test lateralized to the left ear. 



CASE 79 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma (purulent 
otorhea of 7 years duration) complicated by serous then 
suppurative labyrinthitis (loss of balance and a sense of rotation 
then complete loss of hearing) 



Explain the 

following 

manifestations 



Severe sense of rotation: vertigo due to serous labyrinthitis and 

irritation of the vestibular receptors 

Complete relief of the condition of vertigo: due to suppurative 

labyrinthitis leading to complete destruction of the vestibular 

receptors and so the patient relies on the receptors of the 

healthy ear and subsequently vertigo improves 

Complete loss of hearing: due to destruction of the receptors of 

hearing 

Weber tuning fork test lateralized to the left ear: the type of 

complete hearing loss due to destruction of the cochlear 

receptors is sensorineural leading to dead ear and so the patient 

hears the tuning fork in his healthy normal ear with good nerve 

function 



Further 
examination 
&/or 
investigations 



Audiogram 

CT scan 

Culture and antibiotic sensitivity test 

Vestibular tests for posture 



Treatment 



Tympanomastoidectomy for cholesteatoma 

Antibiotics 

Avoid labyrinthectomy as this may lead to spread of infection 

and meningitis 



95 



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Case 80: A 50 year old female presented to the ENT clinic complaining of a 
change of her voice. On examination, there was a firm neck swelling that was 
non-tender and progressively increasing in size över the last 3 months. The 
patient gave a history that during the last year food may arrest at the root of the 
neck especially solid bulky food. 



CASE 80 



Diagnosis & 
reasons 



Plummer Vinson disease (history of dysphagia över the last year 
with a sensation of arrest of food at the root of the neck) 
complicated by hypopharyngeal malignancy (common 
occurrence after Plummer Vinson disease with development of 
new symptoms of malignant invasion as change of voice and 
metastatic lymph node) 



Explain the 

following 

manifestations 



Further 
examination 
&/or 
investigations 



Change in her voice: is due to spread of the hypopharyngeal 
malignancy to the vocal fold or the vocal fold muscle or its nerve 
supply if the lesion is postcricoid it might lead to fixation of the 
cricoarytenoid joint causing vocal fold fixation 
Firm neck swelling progressively increasing size: suspicious of 
malignant metastatic lymph nodes the hypopharnx especially the 
pyriform fossa is considered one of the silent areas of the head 
and neck that present by a metastatic lymph node befor eclear 
evidence of the primary tumor 

• Hypopharyngoscopy and biopsy 

• CT scan 

• Barium swallow 

• Lateral view neck plain X-ray 



Treatment 



Total laryngopharyngectomy and radical neck dissection 

Radiotherapy 

Chemotherapy 

Palliative treatment 



Case 81 : A male patient 52 years old asked medical advice because of severe 
headache of 2 days duration that was not relieved by the usual analgesics. He 
gave a history of long standing yellowish foul smelling discharge from the left 
ear. On examination, the patient was found to be irritable and avoiding light. 
Temperature was 39 C and pulse rate was 96/min. there was marked stiffness of 
the neck. Otologic examination revealed a left attic perforation with granulation 
shovving through it. 



CASE 81 



Diagnosis & 
reasons 



Left chronic suppurative otitis media - cholesteatoma (long 
standing foul smelling ear discharge, left attic perforation) 
complicated by meningitis (headache, irritability, temperature 39 
C, neck stiffness) 



Explain the 

following 

manifestations 



Severe headache: due to increased intracranial tension 

accompanying meningitis 

Foul smelling ear discharge: accompanies cholesteatoma due to 

bone necrosis and infection by anerobic organisms 

İrritability: due to increased intracranial tension and some 

encephalitis accompanying meningitis 

Avoiding light: photophobia due to some optic neuritis 

accompanying meningitis as the optic nerve passes through the 

meninges 

Granulations: usually accompany a cholesteatoma and are 

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o^JaJl M4I 




present around it between the cholesteatoma and the necrosed 
bone and diseased tissue 


Further 
examination 
&/or 
investigations 


• Lumbar puncture 

• CT scan 

• Audiogram 

• Culture and antibiotic sensitivity test 


Treatment 


Antibiotics that cross the blood brain barrier 

Brain dehydrating measures - diuretics, mannitol 10% 

Tympanomastoidectomy for the cholesteatoma 



Case 82: A 5 year old child underwent an adenotonsilectomy operation. On 
discharge from the recovery room, the child was conscious, blood pressure 
110/80, pulse rate 100/min and the respiratory rate 16/min. Four hours later, the 
nurse reported to the resident that the pulse rate became 140/min, blood pressure 
100/70 and the child vomited 150 cc of blood. 



CASE 82 



Diagnosis & 
reasons 



Reactionary post tonsillectomy hemorrhage (4 hours after an 
adenotonsillectomy operation, rising pulse, vomiting of 150 cc of 
blood) 



Explain the 

following 

manifestations 



Rising pulse 100 to become 140/min: is an indication of blood 

loss as the first compensatory mechanism in the circulatory 

system is tachycardia 

Small fail in blood pressure: the blood pressure is compenated 

by the rising pulse when the heart starts to fail the blood 

pressure drops indicating hypovolemic shock 

Vomited blood: is swallowed during the post operative period 

and is vomited because it causes gastric irritation it is black in 

color due to the formation of acid hematin 



Further 
examination 
&/or 
investigations 



Hemoglobin percentage 

Bleeding profile and compare it to preoperative 

investigations 

Blood grouping and preparation of blood transfusion 

Continuous observation of pulse and blood pressure 



Treatment 



Antishock measures (fluid and blood transfusion, steroids) 
Rapid control of bleeding by readmitting to the operation room 
and controlling the bleeding which could be either from the 
adenoid site or the tonsil bed 



Case 83: A male patient 47 years old presented to the otologist because of pain in 
the left ear of 2 days duration. Pain was throbbing in character and increased in 
severity during mastication. The patient gave a history of 2 similar attacks in the 
last six months. On examination, movements of the left auricle were painful and a 
circumscribed reddish swelling was found arising from the outer portion of the 
posterior meatal wall. A painful tender swelling obliterated the retroauricular 
sulcus. Tuning fork testing revealed positive Rinne on both sides and VVeber was 
centralized. 



CASE 83 



Diagnosis & 
reasons 



Recurrent furunculosis of the left external auditory canal (3 
attacks, throbbing pain, increases with mastication and 
movements of the auricle, circumscribed reddish swelling in the 
outer portion of the posterior meatal wall) 



Explain the 



Throbbing pain: indicates an abscess as the pus is under 

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following 
manifestations 



tension 

Increased pain with mastication: due to movements of the outer 

cartilaginous canal with movements of the jaw; the furuncle 

always arises in the outer cartilaginous canal as it contains hair 

follicles and sebaceous glands from which the furuncle arises 

from 

Movements of the lef t auricle are painful: for the same reason as 

mastication 

Painful tender swelling obliterated the retroauricular sulcus: this 

is the post auricular lymphadenitis it obliterates the 

retroauricular sulcus because it causes edema in the 

subcutaeous tissue superficial to the periosteum 

Positive Rinne and Weber centralized: the furuncle is not large 

enough to cause conductive hearing loss and so the tuning fork 

tests are normal 



Further 
examination 
&/or 
investigations 



Investigations for diabetes mellitus (in a case with 
recurrent furunculosis it is the most probable cause, the 
investigations are basically a glucose tolerance curve with 
fasting and every hour glucose test in blood) 



Treatment 



Systemic antibiotic 

Analgesic 

Control of diabetes 

Local antibiotic ointment or glycerine icthyol as a hygroscopic 

agent to help drainage of the furuncle 

Never incise the furuncle surgically as this may lead to 

perichondritis of the auricle and consequently cauliflower ear 

due to fibrosis and deformity of the auricle 



Case 84: A 35 year old male suffered from fever and headache for 5 days for 
which he received antibiotics and analgesics. The symptoms subsided except for 
the headache. 2 weeks later there was right side body weakness and the patient 
complained of vertigo. Nystagmus had no specific direction. Otologic 
examination revealed a right attic perforation with a foul smelling discharge 
pouring from it. 



CASE 84 


Diagnosis & 
reason s 


Right chronic suppurative otitis media - cholesteatoma (right 
attic perforation with a foul smelling discharge) complicated by 
right cerebellar abscess (fever, headache, right side body 
weakness, vertigo, nystagmus with no specific direction) 


Explain the 

follovving 

manifestations 


Headache: due to increased intracranial tension 

Fever: during the encephalitic stage of the brain abscess it 

subsides at the end of this stage and the headache remains 

Right side body weakness: weakness in a cerebellar abscess is 

due to hypotonia and is on the same side as the abscess 

Vertigo: due to incoordination of movement leading to imbalance 

Nystagmus with no specific direction: this is not nystagmus of 

inner ear origin and so it has no specific direction 

Attic perforation: means perforation in the pars flaccida - the 

common site for cholesteatoma 


Further 

examination 

&/or 


• CT scan with contrast 

• MRI 

• Audiogram 



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investigations 
Treatment 



• Culture and antibiotic sensitivity for the ear discharge 
Drainage or excision of the brain abscess neuro surgically 
according to the CT scan findings whether acute or chronic 
abscess 
Tympanomastoidectomy for the cholesteatoma 



Case 85: A female patient 51 years old was admitted to the hospital because of 
severe dysphagia of 2 months duration. The condition started by experiencing 
difficulty in swallowing solid food that arrested at the root of the neck but for the 
last few days even fluids became also difficult to swallow. She had change of her 
voice of one month duration and a difficulty in breathing for a few days. She gave 
a history of dysphagia över the last 10 years. On examination, she had stridor, 
marked pallor of the mucous membrane of the oral cavity, glazed tongue and 
marked loss of weight. Examination of the neck revealed bilateral mobile hard 

upper deep cervical lymph nodes. The laryngeal click is absent. 

CASE 85 



Diagnosis & 
reasons 



Plummer Vinson disease (history of dysphagia över ten years in 
a female patient) that lead to postcricoid carcinoma (progression 
of dysphagia över the last two months, absent laryngeal click) 



Explain the 

following 

manifestations 



Progressive dysphagia: it is an intermittent dysphagia when the 

condition was due to Plummer Vinson disease because of the 

presence of pharyngeal webs then when malignant change 

occurs the dysphagia is towards solid food with a sensation of 

arrest of food at the root of the neck then it progresses when the 

tumor grows to become an absolute dysphagia to fluids as well 

and even in more severe cases to the patients own saliva and the 

patient may experience spill över into the larynx with subsequent 

cough and respiratory distress namely choking 

Change of voice: due to laryngeal involvement either directly or 

involvement of the recurrent laryngeal nerve, the cricoarytenoid 

joint or the laryngeal musculature 

Difficulty in breathing and stridor: is due to laryngeal or tracheal 

involvement by the malignancy leading to respiratory 

obstruction or could be due to choking because of severe 

absolute dysphagia 

Marked pallor of the mucous membrane of the oral cavity: 

Plummer Vinson disease is accompanied by marked iron 

deficiency and pernicious anemia 

Glazed tongue: Plummer Vinson disease is accompanied by 

glossitis due to pernicious anemia 

Bilateral mobile hard upper deep cervical lymph nodes : due to 

lymph node metastasis 

Absent laryngeal click: postcricoid carcinoma is present behind 

the cricoid cartilage and so displaces the larynx anteriorly 

causing absence of the natural click that occurs when the larynx 

is moved sidevvays against the bodies of the cervical vertebra 



Further 
examination 
&/or 
investigations 



Complete blood picture 

General investigations 

Hypopharyngoscopy and biopsy 

CT scan neck 

Barium swallow 

Lateral view plain X-ray 

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Total laryyngopharyngectomy with radical neck dissection 

Radiotherapy 

Chemotherapy 

Palliative treatment 



Case 86: A 30 year old female suddenly noticed a heaviness in the right side of 
the face accompanied by a burning sensation of the right eye when she washed 
her face. There was accumulation of food in the right vestibule of the mouth. Ali 
food had a metallic taste. The patient could not tolerate loud sounds. She 
received the proper çare and treatment and after one month there was marked 
improvement of her condition. There was no fever ali through her illness and both 
tympanic membranes were normal. There was no hearing impairment. 



CASE 86 


Diagnosis & 
reasons 


Right lower motor 
onset and marked 
month) 


neuron facial paralysis - BeM's palsy (sudden 
improvement of her condition after one 


Explain the 

follovving 

manifestations 


Heaviness in the right side of the face: due to paralysis of the 
facial muscles the face tissue feels heavy and drops downwards 
by gravity 


Burning sensation of the eye when washing the face: the eye is 

exposed as the eyelids are unable to close completely and so 

water and soap cause a burning sensation in the eye when 

vvashed 

Accumulation of food in the right vestibule of the mouth: due to 

paralysis of the buccinator muscles that pushes food into the 

oral cavity during mastication so when paralyzed food simply is 

not pushed into the oral cavity and accumulates outside the 

teeth in the oral vestibule 

Metallic taste: due to paralysis of the chorda tympani nerve so 

food is felt by the trigeminal nerve (lingual nerve) only and this 

gives the metallic taste 

Could not tolerate loud sounds: due to paralysis of the stapedius 

muscle that contracts and holds back the stapes if loud sound is 

exposed to the ear - absent acoustic ref lex 

Marked improvement of her condition: usually cases of Bell's 

palsy especially in the young age improve greatly and in a short 

period of time 


Further 
examination 
&/or 
investigations 


• Topgnostic test 
tests for taste 

• Electrodiagnost 
(electroneurono 

• CT scan to exlu< 

• Audiogram 


s as shirmer's test, salivary pH, gustatory 

ic tests for the facial nerve function 

graphy, electromyography) 

ie other causes of facial nerve paralysis 


Treatment 


Steroids immediately after the onset of paralysis 

Antivirals as the possibility of viral infection is there 

Surgical exploration and decompression of the nerve from 

edema if the electroneuronography test for facial nerve function 

shows a 90% degeneration of the nerve fibers within 2 weeks 

from the onset of paralysis 

Çare of the eye to avoid corneal ulceration 

Çare of the muscles by physiotherapy 

Follow up electromyography to detect early recovery of the facial 



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Case 87: A child 4 years old presented to an ENT specialist because of snoring of 
two years duration. His mother reported that her son has persistent mucoid nasal 
discharge that becomes sometimes purulent. For the last month, she began to 
notice that he does not respond to sounds as before. On examination, the mouth 
was found öpen; both tonsils were found enlarged. Both drum membranes were 
found intact. 



CASE 87 


Diagnosis & 
reasons 


Adenoid and tonsillar hypertrophy (snoring, öpen mouth, 
enlarged tonsils) complicated by bilateral otitis media with 
effusion (does not repsond to sounds, intact drum membranes) 


Explain the 

follovving 

manifestations 


Snoring: indicates adenoid hypertrophy due to bilateral nasal 
obstruction causing the child to breathe from his mouth as well 
causing palatal vibrations producing the snoring sound 
Mucoid nasal discharge that may become purulent: due to 
infection in the adenoid and the paranasal sinuses especially the 
ethmoid 

Does not respond to sounds as before: is due to eustachian tube 
obstruction and subsequent otitis media with effusion and 
possible the presence of fluid behind the tympanic membrane 
Drum membrane intact: otitis media with effusion does not 
cause perforation of the tympanic membrane the tympanic 
membrane is only retracted and may show a hair line indicating 
fluid behind the drum 


Further 
examination 
&/or 
investigations 


• Audiogram will show an air bone gap due to conductive 
hearing loss 

• Tympanogram may show type C curve indicating a 
negative middle ear pressure or a type B curve indicating 
presence of fluid behind the drum 

• X-ray lateral view skull will show a soft tissue shadow with 
narrowing of the nasopharyngeal airway 

• General investigation in preparation for 
adenotonsillectomy 


Treatment 


Adenotonsillectomy 

Trial medical treatment for otitis media with effusion namely 

antibiotics and steroids 

If otitis media with effusion does not improve bilateral 

ventillation tube insertion - grommet tubes 



Case 88: A male patient 63 years old presented to the hospital because of severe 
nose bleeding of about 20 min. Pulse rate 120/min, blood pressure 100/60. He 
gave a history of receiving treatment for hypertension. 



CASE 88 



Diagnosis & 
reasons 



Severe epistaxis (nose bleeding, pulse 120/min) caused by 
systemic hypertension 



Explain the 

follovving 

manifestations 



Pulse 120/min: this rise in pulse indicates that the epistaxis is 
severe leading to shock tacchycardia is a compensatory 
mechanism by the heart to correct for the rapid blood loss 
100/60 blood pressure: in a hypertensive patient is considered 
low blood pressure and is a dangerous sign that the patient is 
shocked 

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Further 
examination 
&/or 
investigations 



• General investigations for a hypertensive patient 



Treatment 



Antishock measures (fluid transfusion, blood transfusion, 

steroids, controlled sedation) 

Stop the bleeding (anterior or posterior nasal pack if failed 

arterial ligation or endoscopic control of bleedin 

Control systemic hypertension in the future to prevent a 

recurrent episode of epistaxis 

Correction of any post hemorrhagic anemia by iron therapy 



Case 89: A female patient 18 years old sought medical advice because of 
inability to close her right eye of 3 days duration. She gave a history of 
longstanding scanty bad smelling discharge from her right ear. On examination, a 
right attic perforation was found. 



CASE 89 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma 
(longstanding history of bad smelling discharge from the right 
ear and a right attic perforation) complicated by right lower 
motor neuron paralysis (inability to close the right eye of 3 days 
duration) 



Explain the 

following 

manifestations 



İnability to close the right eye: is due to paralysis of the 
orbicularis occuli muscle responsible for the final stage of firm 
eye closure that is supplied by the facial nerve 
Bad smelling ear discharge: due to bone necrosis by the 
cholesteatoma and the infection by anerobic organisms 
Attic perforation: the cholesteatoma is commonly present in the 
region of the attic of the middle ear and the perforation appears 
in the pars flaccida 



Further 
examination 
&/or 
investigations 



CT scan to show the extent of the cholesteatoma 

Audiogram 

İnvestigations for facial nerve level of paralysis 

(topognostic tests: Shirmer's test, acoustic reflex if 

possible, salivary pH, gustatory taste senation tests) 

İnvestigations for the integrity of the facial nerve 

(electroneuronography and electromyography) 



Treatment 



Tympanomastoidectomy for cholesteatoma 

Management of the facila nerve condition according to the 

operative findings usually it is an inflammation with granulation 

tissue and after removal of the cholesteatoma the nerve will 

recover this can be followed up by the facial nerve integrity tests 

Çare of the eye 

Çare of the muscles by physiotherapy 



Case 90: A male patient 25 years old asked for medical advice because of intense 
headache together with discharge from the right ear. The ear discharge was 
scanty, foul smelling and of five years duration. Headache started six weeks ago, 
increased in the last two weeks and became associated with vomiting, vertigo 
and blurring of the vision. On examination, the patient was found not alert, having 
abnormal gait with tendency to fail to the right side. Temperature was 36 C and 



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the pulse rate was 60/min. Examination of the ears revealed right attic perforation 
and tuning fork testing shovved a right conductive hearing loss. 



CASE 90 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma (scanty 
foul smelling five year duration ear discharge, right attic 
perforation) complicated by right cerebellar abscess (headache, 
vomiting, blurring of vision, vertigo, abnormal gait and tendency 
to fail to the right) 



Explain the 

following 

manifestations 



Intense headache: due to increased intracranial tension 

Vomiting: due to increased intracranial tension and pressure on 

the chemoreceptor trigger zone 

Vertigo: damage of the vestibular centers in the cerebellum and 

is usually accompanied by nystagmus 

Blurring of vision: due to increased intracranial tension and 

papilledema of the optic disc 

Patient was not alert: the brain abscess causing some stupor - 

disturbed level of conciousness 

Abnormal gait: due to imbalance and incoordinated body 

movements 

Tendency to fail to the right: due to hypotonia and weakness of 

the muscles on the right side of the body the same side as the 

cerebellar abscess 

Temperature 36 C: commonly a brain abscess is accompanied 

by subnormal temperature due to affection of the heat regulatory 

center 

Pulse rate 60/min: commonly a brain abscess is accompanied by 

slowness of the pulse bradycardia due to affect of the 

cardiovascular center 

Tuning fork tests show a conductive hearing loss: due to 

cholesteatoma causing destruction in the ossicular chain 

especially the incus long process and the stapes suprastrucure 



Further 
examination 
&/or 
investigations 



Search for other clinical neurological manifestations of 

cerebellar attaxia: tremors, incoordicated body 

movements, slurred speech, finger nose test, 

dysdiadokokinesia) 

CT scan with contrast to show the cerebellar abscess 

Audiogram 

Complete blood picture for leucocytic count it is high so 

long as there is an abscess 

Fundus examination for papilledema 

Avoid lumbar puncture as it might lead to brainstem 

conization and death 

Culture and antibiotic sensitivity test 



Treatment 



Tympanomastoidectomy for the cholesteatoma 

Drainage or excision of the cerebellar abscess neurosurgically 

according to the findings in the CT scan 

Antibiotics that cross the blood brain barrier 

Brain dehydrating measures to lower the increased intracranial 

tension 



Case 91: A male patient 50 years old presented with nasal obstruction and 
impairment of hearing in the right ear of 4 months duration. On examination, the 

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patient had nasal tone of voice and on asking him to say AAA the right side of the 
soft palate was found immobile. Examination of the neck revealed bilateral 
enlargement of the upper deep cervical lymph nodes which were hard in 
consistency. Examination of the right ear showed retraction, loss of luster and a 
waxy appearance of the tympanic membrane. 



CASE 91 


Diagnosis & 
reasons 


Nasopharyngeal carcinoma (impairement of hearing in the right 
ear with a retracted tympanic membrane, nasal obstruction, 
imobility of the right side of the soft palate) with bilateral lymph 
node metastasis (bilateral enlarged upper deep cervical lymph 
nodes that are hard in consistency) 


Explain the 

following 

manifestations 


İmpairement of hearing in the right ear: due to destruction of the 

nasopharyngeal orifice of the eustachian tube causing otitis 

media with effucion due to poor aeration of the middle ear 

Nasal tone of voice: due to palatal paralysis it is a rhinolalia 

aperta where the letter K and G are replaced by A 

Right side of the soft palate is immobile: due to involvement of 

the palatal muscles and nerves by the nasopharyngeal 

carcinoma present above the soft palate 

Hard upper deep cervical lymph nodes that are bilateral: lymph 

node metastasis tne nasopharynx commonly sends bilateral 

lymph node metstasis 

Loss of lustre and waxy appearance of the tympanic membrane: 

due to retraction and poor aeration of the middle ear, waxy 

appearance means that the drum has lost its lustre and is no 

longer shining or glistening 


Further 
examination 
&/or 
investigations 


• CT scan 

• Nasopharyngoscopy and biopsy 

• Audiogram and tympanogram 


Treatment 


Radiotherapy for the primary lesion and the secondaries 

Radical neck dissection for the residual secondaries in the 

lymph nodes if they are not cured by the radiotherapy 

T-tube insertion in both drum membranes as the damage in the 

eustachian tube is permanent 

Chemotherapy in certain tumors 

Palliative treatment for terminal cases 



Case 92: A male patient 23 years old presented with impairment of hearing in 
both ears of about 4 years duration. Hearing impairment was more noticed in the 
right ear. He gave a history of longstanding on and off yellowish discharge from 
both ears. He had no vertigo or tinnitus. Examination of the ears revealed bilateral 
dry central kidney shaped perforations of both drum membranes. Tuning fork 
testing demonstrated bilateral negative Rinne test and Weber test lateralized to 
the right ear. 



CASE 92 



Diagnosis & 
reasons 



Bilateral chronic suppurative otitis media - tubotympanic type 
(longstanding on and off yellowish ear discharge, impairement of 
hearing, bilateral central kidney shaped perforations) 



Explain the 

following 

manifestations 



Longstanding on and off yellowish ear discharge: in 
tubotympanic otitis media the discharge is intermittent and 
appears with every bout of infection 



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Ta 


No vertigo and tinnitus: as the ears are drained every time of 
infection there is no vertigo or tinnitus it might be present during 
the attack of infection 

Dry central kidney shaped perforations of the drum: dry as there 
is no infection at the moment, central indicating that there is a 
rim of drum membrane and annulus ali around and that it is not a 
cholesteatoma, kidney shaped the drum membrane receives its 
blood supply from the annulus and along the handle of the 
malleus so in case of necrosis of the drum due to infection the 
areas most further away from the blood supply take a kidney 
shaped appearance 

Bilateral negative Rinne test: indicating that bone conduction is 
better than air conduction that is the patient has a bilateral 
conductive hearing loss 

Weber lateralized to the right ear: indicating that the conductive 
hearing loss on the right is greater than the left this could be due 
to a larger perforation or exposure of the round window by the 
perforation (round window baffle effect) or an auditory ossicular 
disruption accompanying the perforation - it also could indicate 
a sensorineural affection of the left ear and this is unlikely as 
there is no tinnitus and the patient subjectively feels that his 
right ear is worse 


Further 
examination 
&/or 
investigations 


• Audiogram to detect type of hearing loss and have a 
documented record of the hearing status of the patient 

• X-ray mastoid 

• Culture and antibiotic sensitivity of the ear discharge 


Treatment 


Myringoplasty or tympanoplasty for both ears with six month 
interval starting with the worst hearing ear f irst 
Antibiotics for any ear infection if it occurs 



Case 93: A 10 year old child presented to the outpatient ENT clinic because of 
severe headache of 5 days duration which did not respond to the usual 
analgesics. His mother reported that her son had his right ear discharging for the 
last 2 years. On examination, the child's general health was bad, he was irritable 
and his temperature was 39 C, pulse 100/min and there was marked neck 
stiffness. Examination of the right ear revealed fetid aural discharge from an attic 

perforation. 

CASE 93 



Diagnosis & 
reasons 



Right chronic suppurative otitis media - cholesteatoma (fetid 
right ear discharge for the last 2 years, attic perforation) 
complicated by meningitis (headache, irritable, temperature 39 C, 
neck stiffness) 



Explain the 

following 

manifestations 



Severe headache: due to increased intracranial tension with 

stretch of the dura overlying the brain 

General health is bad: due to the marked toxemia that 

accompanies meningitis 

İrritable: due to some encephalitis accompanying meningitis 

Marked neck stiffness: due to meningeal inflammation 

Fetid aural discharge: means a bad smelling ear discharge due 

to bone necrosis by the cholesteatoma and infection by anerobic 

organisms 



Further 



• Lumbar puncture to diagnose the condition 



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examination 

&/or 

investigations 



• CT scan for the ear to show the cholesteatoma 

• Audiogram 



Culture and antibiotic sensitivity 



Treatment 



Antibiotics that cross the blood brain barrier 
Lowering intracranial tension (diuretics, mannitol 10%) 
Repeated lumbar puncture to lower intracranial tension 
Tympanomastoidectomy for the cholesteatoma 



Case 94: A male patient 32 years old was referred from a Neurosurgeon for 
otological evaluation. The patient had a motor car accident 2 days before. He 
gave a history of loss of consciousness for a few minutes together with bleeding 
from the right ear. The patient stated that he could not move the right side of his 
face since the recovery of consciousness. On examination, blood clots were 
found in the right external auditory meatus, ecchymosis of the right tympanic 
membrane and a central posterior perforation with irregular edges could be seen. 
Tuning fork examination revealed Rinne test was negative in the right ear and 
positive in the left ear. Weber test was lateralized to the right ear. The patient 
could not close the right eye or move the right angle of his mouth. 



CASE 94 


Diagnosis & 
reasons 


Right longitudinal fracture of the temporal bone (trauma in a 
motor car accident, right ear bleeding) complicated by right 
lower motor neuron facial paralysis (inability to move the right 
side of the face) 


Explain 
follovvin 
manifes 


the 

g 

»tations 


Bleeding from the right ear: otorrahgia due to a torn tympanic 

membrane and a fracture in the roof of the external auditory 

canal 

Central perforation with irregular edges: traumatic rupture of the 

tympanic membrane due to the fracture 

Rinne test negative in the right ear: due to conductive hearing 

loss 

Weber test lateralized to the right ear: conductive hearing loss 


Further 
examination 
&/or 
investigations 


• CT scan to delineate the longitudinal fracture in the 
temporal bone 

• Topognostic test to determine the level of facial nerve 
paralysis (shirmer test, acoustic reflex, salivary pH, 
gustatory taste test) 

• Tests for integrity of the facial nerve 
(electroneuronography, electromyography) 

• Audiogram 


Treatment 


Exploaration and repair of the facial nerve if the 

electroneuronography shows a 90% degeneration within one 

week of the onset of paralysis 

Myringoplasty for the perforation of the tympanic membrane if it 

does not heal spontaneously 

Ossiculoplast for any auditory ossicular damage 



Case 95: A 19 year old girl presented to the ENT specialist because of bleeding 
from the right ear, impairment of hearing and tinnitus following a slap on the right 
ear one hour before. On examination, blood clots were found in the right external 
auditory meatus, the drum membrane showed a bluish coloration along the 
handle of the malleus and a central anteroinferior perforation with irregular 



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contused edges. Tuning fork testing revealed Rinne test negative in the right ear 
and Weber lateralized to the right ear. 



CASE 95 



Diagnosis & 
reasons 



Traumatic perforation of the right tympanic membrane (slap to 
the ear, central anteroinferior perforation with contused edge) 



Explain the 

following 

manifestations 



Bleeding from the right ear: due to tear in the drum membrane 
Impairement of hearing and tinnitus: due to tympanic membrane 
perforation causinga conductive hearing loss 
Irregular contused edge: due to the tear in the tympanic 
membrane caused by physical trauma the slap to the ear 
Weber test lateralised to the right ear: indicating a conductive 
hearing loss caused by the tympanic membrane perforation 



Further 
examination 
&/or 
investigations 



Audiogram 



Treatment 



Conservative treatment (avoid water in the ear, avoid blowing the 
nose forcibly) usually most perforations heal spontaneously in 3- 
4 weeks time 
Myringoplasty if perforation persists after 6 weeks time 



Case 96: A male child 3 years old presented to the emergency room of the 
hospital at 3 am because of severe respiratory distress of one hour duration. His 
mother stated that her child was awakened from sleep by cough, hoarse voice 
and respiratory distress. On examination, temperature 39 C, pulse rate 110/min 
and the respiratory rate was 30/min. The child had stridor more manifest during 
inspiration, he had working ala nasi and supraclavicular recession. However, he 
was not cyanosed. 



CASE 96 



Diagnosis & 
reasons 



Acute laryngotracheobronchitis - croup (sudden onset of 
marked respiratory distress with biphasic stridor more marked 
with inspiration with cough) 



Explain the 

following 

manifestations 



Cough: due to inflammation of the larynx trachea and bronchi 

there is increased viscid mucous secretions in the airway 

causing cough 

Hoarse voice: due to subglottic edema extending to the 

undersurface of the true vocal folds leading to change of voice 

Temperature 39 C: usually temperature is lower than that but it 

may be elevated as in this case according to the type of the 

organism causing the condition 

Pule rate 110/min: indicating affection of the heart by heart 

failure 

Stridor more manifest during inspiration: stridor means a sound 

produced due to respiration against partial airway obstruction it 

is more manifest during inspiration as the main power of 

breathing occurs during inspiration against the subglottic edema 

in the airway 

VVorking ala nasi and recession of the supraclavicular areas: is 

an indication of forcible breathing against an obstructed airway 

due to the negative pressure created inside the chest cage 

Not cyanosed: indicates that the patient has not reached the 

critical level of low oxygenation that leads rapidly to death but 



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one shoiuld not wait until such an occurrence - also in anemic 
patients that do not manifest cyanosis until vary late when the 
condition is very advanced 


Further 
examination 
&/or 
investigations 


• Chest X-ray 

• Laryngoscopy 

• İnvestigations to detect rapidly heart failure 


Treatment 


Urgent steroids in large doses 
Very close observation 
Oxygenation by humidified oxygen 
Endotracheal intubation if required 
Tracheostomy in advanced cases 
Correction of heart failure 
Antibiotics to prevent complications 



Case 97: A female patient 23 years old asked for medical advice because of 
sudden inability to close the right eye and deviation of the angle of the mouth on 
smiling to the left side of 2 days duration. She noticed discomfort on hearing loud 
sounds and a change in the sense of taste in her mouth. She gave no history of 
trauma or aural discharge prior to her illness. ENT examination revealed inability 
to mobilize ali the muscles of the right side of the face. The right external auditory 
meatus and the tympanic membrane were found normal. 



CASE 97 


Diagnosis & 
reasons 


Right lower motor neuron paralysis - Bell's palsy (sudden onset 
of facial paralysis with no apparent cause) 


Explain the 

follovving 

manifestations 


Deviation of the angle of the mouth to the left side during 
smiling: due to paralysis of the orbicularis oris muscle with its 
component the levator anguli oris this occurs with lower motor 
neurone facial paralysis but with upper neuron paralysis the 
mouth is paralysed also with voluntary movements if you ask the 
patient to show his teeth but with involuntary emotional 
movements as a spontaneous smile or laugh the mouth may 
move normally 

Discomfort on hearing loud sounds: due to paralysis of the 
stapedius muscle that prevents loud sounds from causing 
vibration of the stapes and hence lowers the amount of energy 
entering the inner ear 

Change in the sense of taste: due to paralysis of the chorda 
tympani nerve 


Further 
examination 
&/or 
investigations 


• Topognostic tests for the lavel of facial nerve paralysis 
(Shirmer's test, acoustic reflex, salivary pH, gustatory 
taste tests) 

• İnvestigations for the integrity of the facial nerve 
(electroneuronography, electromyography) 

• İnvestigations to exclude any hidden cause for facial 
paralysis (CT scan, MRI) 


Treatment 


Urgent therapy with steroids (1mgm/kgm body weight) and hen 
taper the dose 

Exploration and decompression of the facial nerve in its course 
in the temporal bone if the electroneuronography results reach 
90% degeneration in a period of 2 weeks (14 days) from the 
onset of the paralysis 



108 



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Care of the eye to prevent the occurrence of lagophthalmus and 

corneal ulceration (drops, ointment, coverage) 

Care of the muscles by physiotherapy 

Follow up recovery by the return of polyphasic electric potentials 

in the electromyography tests 



Case 98: A 54 year old male patient who is a heavy smoker presented to the ENT 
clinic with change of his voice in the form of hoarseness of 2 months duration. 
There was no recent laryngitis or voice abuse. Laryngeal examination was not 
possible. 



CASE 98 


Diagnosis & 
reasons 


Cancer larynx (heavy smoker, hoarseness of voice of 2 months 
duration) anther possibility is left bronchial carcinoma that has 
caused left recurrent laryngeal paralysis and thus left vocal fold 
paralysis or pancoast tumor in the upper lobe of the lung leading 
to either recurrent laryngeal nerve paralysis and vocal fold 
paralysis 


Explain the 

follovving 

manifestations 


Hoarseness of voice: is due to glottic carcinoma causing 
inability of the vocal folds to coapt their edges and produce 
proper voice or due to vocal fold paralysis causing weakness in 
the production of voice 


Further 
examination 
&/or 
investigations 


• Flexible nasolaryngoscopy under local anesthesia to 
visualize the larynx 

• Chest X-ray to detect bronchial or pancoast tumors 

• CT scan neck and chest 

• Direct laryngoscopy and biopsy 


Treatment 


If cancer larynx total or partial laryngectomy or laser endoscopic 

excision according to the lesion 

If lung or bronchial carcinoma treated accordingly 

Radiotherapy 

Palliative treatment in terminal cases 



Case 99: A 16 year old male patient traveled to Hurghada by airplane. On descent 
there was some headache and earache that subsided after 3 hours. The next day 
he took part in a scuba diving training course, the pain in his forehead became 
rather severe and was not relieved by any analgesics. During the night he became 
feverish with marked nasal obstruction and in the morning there was marked 
bilateral upper eyelid edema. He returned to Cairo and received antibiotic therapy 
and improved slightly but there was no nasal discharge. On the third day of 
antibiotic therapy, he became feverish again 40 C and there was severe 
headache, vomiting and he avoided light. Later his vision was blurred and he was 
very irritable. He was taken to hospital, intensive intravenous antibiotics were 
given and a lumbar puncture performed. His condition improved remarkably 
during the next few days. 



CASE 99 



Diagnosis & 
reasons 



Sinüs barotrauma (descent from height by airpalne and then 
scuba diving) followed by bilateral acute frontal sinusitis (fever, 
nasal obstruction, bilateral eye lid edema) complicated by 
meningitis (fever 40 C, severe headache, vomiting, avoided light, 
blurred vision, irritablity, lumbar puncture improved the 
condition) 



Explain the | Earache: is due to otitic barotrauma due to descent of the 

-109- 



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following 
manifestations 


airplane it improves after sometime due to swallowing and 

aeration of the middle ear throught the eustachian tube 

Severe pain of the forhead and headache following scuba diving: 

due to acute frontal sinusitis initiated by sinüs bartrauma 

Marked bilateral upper eye lid edema: due to frontal sinusitis 

causing edema över the forehead extending downwards the eye 

lids 

No nasal discharge: indicating an obstruction of the nasofrontal 

ducts and no drainage these cases are more liable for 

complications as the pus in the sinüs is not drained 

Fever 40 C: indicates the occurrence of a new complication 

namely meningitis 

Severe headache: due to increased intracranial tension and 

stretch of the meninges especially the dura 

Vomiting: due to increased intracranial tension and pressure on 

the chemoreceptor trigger zone 

Avoided light: due to photophobia accompanying meningitis due 

to some optic neuritis as the optic nerve passes through the 

meninges 

Bluured vision: due to increased intracranial tension and 

pappiledema of the optic disc 

Condition improved after lumbar puncture: due to lowering of 

the increased intracranial tension 


Further 
examiric 
&/or 
investig 


ıtion 
ations 


• Lumbar puncture to diagnose meningitis 

• Fundus examination to see pappiledema 

• CT scan paranasal sinuses and nose 

• Nasal endoscopy 




Treatme 


>nt 


Antibiotics that cross the blood brain barrier 

Repeated lumbar puncture to lower the increased intracranial 

tension 

Lowering the intracranial tension by diuretics and mannitol 10% 

Management of the acute frontal sinusitis by medical or surgical 

treatment 



Case 100: A 35 year old male patient has been complaining över the last 10 years 
of attacks of incapacitating vertigo, tinnitus and decreased hearing. During the 
attack there was a sense of aural fullness, the patient described it as if his ear is 
about to explode. İn between the attacks that usually occur önce or twice a week 
the patient feels fine or may have a minör sense of imbalance. The patient also 
reported that his hearing ability is decreasing över the years. Examination of the 
ears showed bilateral normal tympanic membranes and some non-occluding 
earwax. 



CASE 100 



Diagnosis & 
reasons 



Meniere's disease (attacks of vertigo, tinnitus and decreased 
hearing with aural fullness) 



Explain the 

following 

manifestations 



İncapacitating vertigo: means vertigo severe enough to prevent 
the patient from any balance or movement this usually occurs in 
Meniere's disease due to increased inner ear pressure - 
endolymphatic hydrops - irritating the vestibular receptors 
Tinnitus: due to irritation of the cochlear receptors by the 
increased pressure in the inner ear and due to the presence of a 
certain degree of sensorineural hearing loss 



110 



j^U\ }\£\ 





Decreased hearing during the attack: is due to pressure on the 
cochlear receptors by the increased inner ear pressure 
Aural fullness: is a manifestation alaways present in Meniere's 
attack 

Decreased hearing över the years: is sensorineural in nature and 
occurrs due to damage of the cochlear receptors by the attacks 
över the years it usually starts with the low sound frequency 
reeceptors present in the apical and middle cochlear turns 
Non-occluding ear wax: an associated finding in the ear that has 
no relation to Meniere's disease 


Further 
examination 
&/or 
investigations 


• Audiogram and tympanogram 

• Vestibular functionm tests 

• Posturography 

• CT scan to exclude other causes 


Treatment 


Medical treatment during the attack (diuretics, salt restriction, 

labyrinthine sedatives, systemic sedatives, antiemetics) 

Surgical treatment in certain cases as sac decompression in rare 

cases 

Selective vestibular neurectomy in persistent and resistent 

cases that do not respond at ali to medical treatment and these 

are very rare cases 



1- A male patient 47 years old presented to the otologist because of pain in the 

Left Ear 

of 2 days duration pain was throbbing in character and increased in severity 

during 

mastication. The patient gave a history of 2 similar attacks in the last 6 months. 

On 

examination, movements of the Left Auricle were painful and a circumscribed 

reddish 

swelling was found arising from the outer portion of the posterior meatal wall. 

The retro 

auricular sulcus was obliterated by a painful tender swelling. Tuning fork testing 

revealed +ve Rinne test on both sides and Weber test was centralized. 

a. mention the most likely diagnosis. Give reasons. 

b. Mention ONE important differential diagnosis and state the differentiating 
points. 

c. Mention possible causes for the recurrence of these swellings. 

d. Outline the treatment of this patient. 
2-Discuss nasal polyp. 

3-Discuss the symptoms, signs and treatment of the vocal cord carcinoma. 



JUNE1992 



Answer ali questions: no surgical details are required: 

1-A male patient 50 years old presented with nasal obstruction and impairment of 

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hearing in the right ear of 4 months duration. On examination the patient had a 

nasal 

tone of voice and on asking him to say ah the right side of the soft palate was 

found 

immobile. Of Examination of the neck revealed bilateral, enlargement the upper 

deep 

Cervical lymph nodes which were hard in consistency. Examination of the right 

ear 

showed retraction of the tympanic membrane. Answer the following questions: 

a. State the most likely diagnosis of the case. Give reasons to ensure your 
diagnosis. 

(3 marks) 

b. Mention 2 other possible symptoms or signs impacted in this case. (2 marks) 

c. Name 2 audiological investigations needed for this patient and comment on the 
possible findings. (2marks) 

d. Describe the. Management of this case. (3 marks) 

2-List 3 common causes of referred otalgia; name the responsible nerve in each. 
(3 marks) 

3- Describe the main lines of treatment for acute frontal sinusitis.(3 marks) 
4-List the signs of acute laryngeal obstruction. (4 marks). 




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Answer ali questions: no surgical details are required: 

1- A male Patient. 25 years asked medical advice because of intense headache 

together 

with discharge from the left eat, the ear discharge was scanty foul smelling and of 

5 

years duration. Headache started 6 weeks ago. Increased in the last 2 and 

became 

associated with vomiting, vertigo and blurring of vision. On examination, the 

patient 



112 



was found not alert, having abnormal gait with tendency to fail to the Right side. 

His 

temp was 36°c the pulse was 60/min. examination of the ear revealed it attic 

perforation 

and tuning fork testing showed Right C.H.L. 

I) State the most probable diagnosis of this case. Give reasons. (6 marks) 

II) List the investigations you order to prove your diagnosis. Comment on the 
possible 

findings. (5 marks) 

III) Explain the cause of the following findings. 

• Vertigo. 

• Blurring of vision. 

• Vomiting. 

• Temperature 36°C 

IV) Describe the treatment of this patient 

2- Give a short account on: 

a. Quinsy. (10 marks) 

b. Stridor. (1 marks) 

3- Give a short account on. 

a. Treatment of a case of severe epistaxis (10 marks). 

b. Achalasia of the cardia (10 marks) 






1- A female patient 51 year old was admitted to the hospital because of sever e 
dysphagia of 2 months duration. The condition started by experiencing difficulty 
in 

swallowing solid food, which was arrested at the root of the neck by t of the last 

few 

3- Mention the most important investigations needed in this case. Comment on 

the 

Expected findings. (5 marks). 

2- Give a short account on secretory otitis media. (10 marks). 
3- 

a. Describe the main lines of treatment of BeN's palsy. (5marks). 

b. Enumerate the indications of tracheostomy. (5marks). 

c. Discuss rhinolalia. (5 marks). 

d. Describe the treatment of acute corrosive Oesophagitis. (5 marks). 



113 



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1- A female patient 18 years old seaked medical advise because of inability to 
close her right eye of three days duration she gave a history of days even fluids 
became also difficult to swallow,she had change of voice of one month duration 
and difficulty in respiration for days. She gave a history of dysphagia for the last 
10 years. On examination, the patient had stridor, marked pallor of the mucous 
membrane of the oral cavity, glazed tongue and loss of weight. Examination to 
the neck revealed mobile hard upper deep cervical lymph nodes. The click was 
found absent. 



I) What is the most probable diagnosis? Give reasons to substantiate your 



diagnosis. 



(4 marks) 



Explain the following findings: 

Stridor 

Long history of dysphagia 

Enlarged cervical lymph nodes. 



(2 marks). 
(2 marks). 
(2 marks). 



Discuss the symptom, signs and treatment of malignant maxilla. (10 marks) 
Discuss quinsy. (10 marks) 

Discuss briefly the causes of stridor in young children. (10 marks). 

Enumerate the operative complications of tracheostomy. (5 marks). 

Describe the picture of Barium following conditions. 

Cardiac achalasia. 

Post corrosive esophageal stricture. 

Carcinoma of the midesophagus. (5 marks). 



114 



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June1996 



1- A 30 year old male, with history of chronic frontal sinusitis he spent his last 
holiday in Sharm El Sheik, it was his first visit and enjoyed much diving in Red 
Sea. At the end of his trip he started to complain of mild fever 37.80C, frontal 
headache that increased gradually from morning headache to whole day. The 
patient also complained of mucopurulent nasal and postnasal discharge. He 
consulted a doctor who noticed redness and puff iness över the right frontal 
sinüs, nasal examination revealed pus in the middle meatus, Examination of the 
eye revealed swollen upper eye lid, otherwise the eye moves freely and its 
structures were normal. The Doc. Prescribed ampicillin 500mg tds, Antihistaminic 
and nasal drops.2 days later the patient deteriorated; fever 39.50C, and was very 
toxic, anorexic and the headache was bursting and associated with vomiting neck 
rigidity was also noticed. 

I) What is your diagnosis and give reason. (5 marks) 

II) What are the most important investigations needed to confirm your 
diagnosis. Comment on the possible findings. (5 marks) 

III) What are the other possible complications that can occur in the same 
anatomical region? (5marks). 

IV) How would you manage the case? (5marks). 

2- Discuss: 

• Stridor in children causes and management (5 marks) 

• Different types for deafness and how to differentiate between them. 
(5 marks). 

3- Give a short account on: 

Esophageal causes of dysphagia. 

• Management of Severe epistaxis. 
Otalgia. 

• Complications of Tonsillectomy. 



(5 marks). 

(5 marks). 

(5marks). 

(5 marks). 




115 



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*Time allowed 90 minutes "Ali Questions are to be answered M 

1) A female patient 27 years old asked for medical advice because of sudden 
inability to close the right eye and deviation of the angle of the month on smelling 
to the left side of two days duration. She noticed discomfort on hearing loud 
sounds and a metallic taste in the mouth. She gave no history of trauma or 
discharge from the right ear prior to her illness. E.N.T examination revealed 
inability to mobilize ali the muscles of the face. The right external auditory meatus 
and the tympanic membrane were found normal. 

1- State the most probable clinical diagnosis. Give reasons to support your 
diagnosis. 

2- Explain the following complaints: 
o Discomfort to loud sounds. 
o Abnormal taste. 

3- Describe the management of this case. 

4- Mention the prognosis in such a case. 

2) Describe the symptoms and signs of a malignant maxilla. Describe two 
most important investigations you advise which have their bearing on the 
management. 

3) Define stridor. Enumerate the three most common causes in a 3 years old 
child and describe their management. 

4) Discuss brief ly the complications of adenoids. 



ALL ÛUSTION ARE TO BE ANSVVERED: 



116 



1- A 19 year old girl presented to the ENT specialist because of bleeding from 
the right ear, impairment of following a slap on the right ear one hour before. On 
examination, blood clots were found in the right external auditory meatus, the 
drum membrane showed ecchymosis along the handle of the malleus and a 
central anteroinferior perforation with irregular contused edges could be seen. 
Tuning fork testing revealed: Rinne's test was -ve in the right ear and positive in 
the lef t ear, Weber's test was lateralized to the right ear. 

I) State the most probable diagnosis of this case. Give reasons to 
substantiate your diagnosis. (4 Marks) 

II) Mention ONE important differential diagnosis and describe the 
differentiating points. (4 Marks) 

III) Mention ONE important investigation you should order in this case and 
describe the possible findings. (2 Marks) 

IV) Outline the treatment of this case. (5 marks) 



List the possible complications of this case & describe their management. 
(5 marks) 



o List the indications of tonsillectomy. (3 Marks) 

o Describe the preparation of a child 5 year old for Tonsillectomy. 

(3 Marks) 
o Describe the postoperative çare of a child who underwent tonsillectomy. 

(4 Marks) 

3- A male patient 54ys old presented with change of voice of 2 months 
duration. 

- Mention THREE common important causes to account for his symptom. 

(3 Marks) 

- Describe how ho you reach a definite diagnosis in this case.(7 marks) 

4- A male patient 58 years old presented with sever bleeding from the right 
nostril of 30 minutes duration: 

-Mention the first old measures you do in this case. (2 Marks) 

-Describe the measures you can do to stop bleeding. (4 Marks) 
-Describe how to prevent the recurrence of this bleeding.(4 Marks) 



1. A male child 3years old presented to the emergency department of the 
hospital at 3 AM because of severe respiratory distress of one hour 
duration. His mother stated that her child was awakened from slee by 
cough, hoarse voice and respiratory distress. On examination: Temperature 
was 39C. Pulse rate was 110/mn and the respiratory rate was 30/minute. 
The child had stridor more manifest during inspiration, he had working ala 
nasi and supraclavicular recession. However, he was not cyanosed. 

a. Mention the most probable diagnosis and give reasons to substantiate it. 
5 marks 

b. List 2 imporatnat common differential diagnosis and menion the 
differentiating points. 5 marks 

c. Describe the first-aid measures you advise in this case. 5 marks 

d. Describe other measures you advise to treat this child in case of previous 
measures fail. 5 marks 

2. Discuss the symptoms, signs, diagnosis and treatment of bilateral 

-117- 



secretory otitis media in a child 5 years old. 10 marks 

3. List the common indications of tonsillectomy. Describe briefly the 
postoperative complications of the operation and their management. 10 
marks 

4. List the causes of unilateral recurrent epistaxis. Describe briefly the 
management of a severe case of epistaxis. 10 marks 



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June99 



ALL ÛUESTIONS ARE TO BE ANSVVERED: 

1- A male patient 32-y old was referred from a Neurosurgeon for Otological 
evaluation. The patient has had a motor car accident two days before. He gave a 
history of loss of consciousness for few minutes together with bleeding from the 
right ear. The patient stated that he could not move the right side of his face since 
the recovery of his consciousness. On examination: blood clots were found in the 
right external auditory meatus, ecchymosis of the right tympanic membrane and 

a central posterior perforation with irregular edges could be seen. Tuning Fork 
examination revealed: Rinne's test was negative in the right car and positive in 
the left ear, Weber's test was lateralized to the right ear. The patient could not 
close the right eye, or move the right angle of his mouth. 

1 . State the most likely diagnosis. Give reasons to support it. (5 marks) 

2. Mention four essential investigation you order in this case and comment on the 
possible findings. (5 marks) 

3. Outline the treatment of this case. (4 marks) 

2- Describe the symptoms, signs, diagnosis and complication of adenoids. 

(12 marks) 



118 



3- Enumerate the three most common granulomata of the nose in Egypt. Describe 
the etiology, symptoms, signs, diagnosis and treatment of the commonest. 

(12 marks) 

4- Describe the symptoms, signs, diagnosis and diagnosis and treatment of vocal 
fold carcinoma. (12 marks) 



ALL ÛUESTIONS ARE TO BE ANSVVERED: 

1) A male patient 59 y. old with bilateral neck swelling of 2 month duration of 

insidious onset &progressive course he gave a history of bilateral nasal 

discharge. he reported impairment of hearing of both ear for the last month.On 

examination; 

i) nasal intonation 

ii) bilateral multiple hard swellings deep to sternomastoid 

iii) right palatal paralysis 

iv) both drum membrane is intact & retracted 

v) -ve Rinne test in both ears 

vi) Weber's test was found central 

Ouestions: 

1) type of hearing loss & it's cause 

II) most probable diagnosis & give reasons to support it 

III) type of nasal intonation & it's cause 

IV) mention 3 investigation & comment on the possible findings 

V) ttt of this case 

2) disscus the etiology , symptoms , signs 
, diagnosis & ttt of acute maxillary sinusitis 

3) define stridor ,it's causes in a 5 y old child previously healthy & describe the 
management 

5) discuss the causes &clinical picture & diagnosis & ttt of traumatic rupture 
of tympanic membrane 




September 2000 



1. A male child 3years old presented to the emergency department of the 
hospital at 3 AM because of severe respiratory distress of one hour 
duration. His mother stated that her child was awakened from slee by 
cough, hoarse voice and respiratory distress. On examination: Temperature 
was 39C. Pulse rate was 110/mn and the respiratory rate was 30/minute. 
The child had stridor more manifest during inspiration, he had working ala 
nasi and supraclavicular recession. However, he was not cyanosed. 

a. Mention the most probable diagnosis and give reasons to substantiate it. 
5 marks 

b. List 2 imporatnat common differential diagnosis and menion the 
differentiating points. 5 marks 

c. Describe the first-aid measures you advise in this case. 5 marks 

d. Describe other measures you advise to treat this child in case of previous 
measures fail. 5 marks 

2. Discuss the symptoms, signs, diagnosis and treatment of bilateral 
secretory otitis media in a child 5 years old. 10 marks 

3. List the common indications of tonsillectomy. Describe briefly the 
postoperative complications of the operation and their management. 10 
marks 



119 



4. List the causes of unilateral recurrent epistaxis. Describe briefly the 
management of a severe case of epistaxis. 10 marks 

June 2001 

1) A 15 y. old boy presented to the ENT clinic with severe nose bleeding. On 
examination he looked very pale & history of 2 similar attack & gradual 
progressive nasal obstruction. Ant. Rhinoscopy revealed nothing relevant apart 
from blood clots. 

a) how would you proceed to reach provisional clinical diagnosis. 

b) what are the relevant investigations necessary to reach a final diagnosis. 

c) mention the possible diffrential diagnosis of this case 

d) outline the ttt of this case 

2) discuss symptoms, signs , investigations & ttt O.M.E. 

3) discuss indication & postoperative complication of tracheostomy. 

4) Give an account on localized suppuration in relation to pharynx 



September 2001 

1. 60 years old man presented with hoarsness of voice for six months 
duration, but what aware him was the recent appearance of a lump in the 
lateral side of the neck. 

a. How do you proceed to reach clinical diagnosis in this case? 10 marks 

b. How do you confirm your clinical diagnosis and final diagnosis in this 
case? 10 marks 

c. Mention the possible differential diagnosis of this case. 10 marks 

d. Outline the treatment of this case. 10 marks 

2. Discuss symptoms, signs, investigations and treatment of bilateral 
allergic nasal polypi. 20 marks 

3. Discuss indications, contraindications and preoperative preparation for 
tonsillectomy. 20 marks 

4. Discuss symptoms, signs, investigations and treatment of cholesteatoma. 
20 marks 




120 










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June 2002 



1- a 50 Y. old male patient presented to the ENT clinic with diminution of hearing 
in the right ear and a very firm lump in the upper part of the neck on the right 
side.also the patient complained of occasional bloody nasal discharge 
examination revealed normal left ear,retracted drum membrane and fliud level in 
the right ear . ant. Rhinoscopy was irrelevant.oral examination revealed partial 
immobility of the right side of the soft palate. 
a.state the most probable diagnosis and give reasons. 
b.mention 2 other symptoms or signs 
c.mention the relevant investigations. 
d.describe the lines of ttt. 
2-a.discuss the etiology and ttt of traumatic perforation of the 
the tympanic membrane. 

b.discuss the clinical picture and ttt of acute laryngitis in youg child. 
3-a.discuss ttt of BeN's palsy. 

b.enumerate causes of epistaxis. 
4-a.discuss the etiology of acute sinusitis. 

b.enumerate esophageal causes of dysphagia. 

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September 2002 



2 



1- a 20 Y. old female patient had been complaining of left ear discharge for the 
last five years.the discharge was scanty and foul smelling.five weeks she started 
to suffer from headache which did not respond to usual analgesics.headache 

-121 - 



gradually increased in the last week and become associated with projectile 
vomiting,vertigo and blurring of vision.O/E,the patient was found drowsy,having 
ataxia with tendency to fail to the left side.temperature was 36.5 and pulse was 
60/min examination of the ear revealed İt attic perforation. 
a.what are the most probable diagnosis? 
b.give reasons to support your diagnosis. 
c.what are investigations that can be done to confirm diagnosis. 
d.describe the ttt of this patient. 
2-discuss management of severe epistaxis. 

3-a. describe the sensory nerve supply of external and middle ears and 
enumerate the causes of referred earache. 

b.discuss the clinical and radiological findings in cancer esophygus, post- 
corrosive stricture and cardiac achalsia. 
4-a.define a stridor and enumerate its causes. 
b.discuss the management of bleeding after tonsillectomy. 

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1- a diabetic male patient 60 years old presented with severe illness,repeated 

rigors,marked edema of both eye lids,chemosis of conjunctiva and forward 

proptosis of the right eye ball,one week prior to presentation he started to suffer 

from severe throbbing pain in his nose and he didn't receive any medical 

ttt.examination of the nose showed a small reddish tender swelling in the Rt nasal 

vestibule. 

a.what did the patient develop one week prior the presentation?(5 m) 

b.what are the complication ,the patient developed and explain how this 

complication occur?(5 m) 

c.mention the other symptom and signs do you expect at this stage?(5 m) 

d.how to confirm the diagnosis of this complication and outline the ttt.(5 m) 

2-define otitis media with effusion,mention its symptoms, signs, investigation and 

ttt.(20 m) 

3-a. outline ttt of fractured nasal bones.(10 m) 

b.enumerate the 3 most common granulomata of the nose in Egypt and 
describe the management of the commonest.(10 m) 
4-a.list the investigation you will order in a case of dysphagia and please 
comment on the possible radiological finding in: 
1-cancer esophagus 2-achalasia 3-simple benign stricture (10 m) 

b.vvhat's the effect of bilateral recurrent laryngeal nerve paralysis on phonation 
and respiration? mention the most important 2 causes. 
(10 marks) 
No surgical details are required 

1) A male patient 30y old has been complaining from discharging Rt ear for at 
least 15 years.the discharge was offensive ,scanty&purulent.3days ago he started 
to complain from inability to close Rt eye and the relative noticed deviation of the 
angle of his mouth to the Lt side while smiling.O/E the discharge was coming 
from Rt attic perforation. 

a) What is the possiple diagonosis?Give Reasons. (4Marks) 

b) What is pathogenesis of the complication which patient developed? 
(4 Marks) 

c) What are th possiple clincal signs you should look for? (4Marks) 

d) What are the Investigations you will order in this case and briefly describe 
thefindings? (4Marks) 

e) Briefly state the ttt of this case. (4Marks) 

2) a) Describe the c/p and ttt of Rhinoscleroma. (10Marks) 
b) List the local causes of epistaxis and management of the most common 
type (10Marks) 

-123- 



Mention the causes of Earache (20Marks) 

a) List the causes of Laryngeal obstruction in children (10Marks) 

Mention the ttt of acute corrosive oesophagitis (10Marks) 

SEPTEMBER 2003 



1- a male pt. 30 y. has been complaining from rt. ear dicharge at least 15 years , 

the discharge was offensive , scanty and purulent , 3 days ago he started to 

complain from inability to close rt. eye and the relative noticed deviation of the 

angle of his mouth to the left side while smiling . on examination the discharge 

was coming from rt. attis perforation 

a- wht is the posssible diagnosis ? give reasons ? 4 MARKS 

b- wht is the pathogenesis of the complication which the pt. developed ? 4 

MARKS 

c-wht is the possible clinical signs u should look 4 ? 4 MARKS 

d-wht r the investigation u will order in this case and briefly describe the finding ? 

4 

e- state ttt of this case ? 4 MARKS 




2- 

a- c/p and ttt of rhinoscleroma ? 10 MARKS 

b- list local causes of epistaxis and management of the most common type ? 10 

MARKS 

3- mention causes of earache 20 MARKS 

4- 

a-causes of laryngeal obstruction in children 10 M 

b- mention ttt of acute corrosive esophagitis 10 M 



May 2004 



1) A male patient 25y old has presented with impairment in the Lt ear of 
6years duration .He gave history of long standing on,&off profuse mucopurulent 
discharge form the Rt ear usually follow attacks of common cold,and usually 
stops with medical ttt.Also he gave history of chronic left ear discharge which is 
continous ,scanty,purulent,and offensive which does not respond to medical 
treatment. 5 weeks ago,he started to complain from transient vertigo upon 
pressing on left tragus.Examination revealed Rt dry central kidney 
perforation,and Lt attic perforation .Fistula test was positive in Lt ear,and Tunning 
fork test demontrated bilateral negative.Rinne's test and Weber v s test showed 
lateralization to the Lt ear. 

a) What is the possiple diagonosis of the case(both the original conditon,and 
the complication);give Reasons. (6Marks) 

b) Mention the type of hearing loss the patient suffers from,and comment on 
the tunning fork tests in this patient. (5Marks) 

c) Mention the most important two relevant investigations and comment on 
the possible findings. (5Marks) 

d) Outline the treatment of the case. (4Marks) 

2) Give an account on Diagnosis of Otosclerosis. (10Marks) 

3) Give an account on Posterior Choanal Atresia. (10Marks) 

4) Give an account on Management of Fracture of The Nasal Bones 
(10Marks) 

-124- 



5) Define Stridor,and describe its C/P.c (10Marks) 

6) Enumerate indications of Tracheostomy and mention the most important 
two causes of sudden respiratory obstruction which may occur few days after 
Tracheostomy. (10Marks) 

7) Describe the C/P of Adenoids. (10Marks) 
N.B. No surgical details are required 

September 2004 

1. A 4-year-old child developed severe pain in the right ear together with a 
rise of temperature (39 C) following an attack of acute rhinitis. The child 
received medical treatment which led to the drop of temperature and 
diminution of pain and the mother noticed that her child was unable to 
close his right eye with deviation of the angle of the mouth to the left side 
on crying. 

a. What is the most probable diagnosis of the case (both the original and the 
complication) and explain the etiology of the complication? 5 marks 

b. What are the possible otologic findings? 5 marks 

c. What are the electrophysiologic investigations which may be needed? 5 
marks 

d. How to treat this patient? 5 marks 

2. Give an account on acute mastoiditis. 20 marks 

3. Give an account on etiology, clinical picture, investigations and 
treatment of acute sinusitis. 20 marks 

4. Give an account on sudden stridor in children. 20 marks 

May 2005 

1. A 4 year-old boy was initially referred by his general practioner for 
management of recurrent epistaxis. These did not respond to simple first 
line measures including cautery of the nasal septum. Över a 2-year period 
he was twice admitted for blood transfusion. At the time of admission for 
the second transfusion, the patient complained of difficult breathing 
through the nose, specially the right side. Subsequent examination revealed 
a large mass within the right nasal cavity and nasopharynx. 

a. What is the most probable diagnosis? Give reasons to support your diagnosis 

b. What investigations are indicated? 4 marks 

c. Describe the main histological features of the condition. 5 marks 

d. Outline the treatment of the case. 5 marks 

2. Give an account on etiology, symptoms, signs and treatment of acute 
suppurative otitis media. 20 marks 

3. Give an account on symptoms, signs, investigations and complications of 
adenoids. 20 marks 

4. A) Mention the types and causes of nasal discharge. 10 marks 
B) Mention local causes of epistaxis. 10 marks 




September 2005 



1. A family was enjoying eating watermelon, one of the kids has had a 
sudden bout of severe cough, choking, dyspnea and cyanosis for few 
minutes, then he remained 3 days without symptoms and he started agai 
coughand expectoration of yellowish sputum 

-125- 



a. What is the most probable diagnosis? Give reasons to support your 
diagnosis. 5 marks 

b. Give an account on the possible findings in clinical examination and 
investigations? 10 marks 

c. What is the treatment of such a condition? 5 marks 

2. Give an account on differences between acute suppurative otitis medi 
infants and young children and that of adults. 20 marks 

3. Give an account on: 

a. Management of severe epistaxis 

b. The difference between diphtheria and acute follicular tonsillitis 

4. Enumerate causes of esophageal dysphagia and give an account on 
corrosive esophagitis and post-corrosive stricture. 20 marks 



1. A 52 years old male patient presented with a 3 months history of 
deterioration of hearing in the right ear. For 2 months he had noticed an 
altered sensation on the right side of his face. Also he had noticed a slowly 
progressive hard lump in the neck below his right jaw. Examination 
revealed diminished movement of the right side of his palate and decreased 
sensation to touch and pinprick on the right side of the face. Examination of 
the ear revealed right sided otitis media with effusion, while the left ear 
being essentially normal. An adequate view of the nasopharynx could not 
be achieved with posterior rhinoscopy. 

What is the likely diagnosis? Give reasons to support your diagnosis. 6 

marks 

What investigations might be of value? 5 marks 

What is trotter's triad? 4 marks 

How do you treat this patient? 5 marks 

2. Give an account on: Traumatic perforation of the tympanic membrane. 10 
marks Indications, contraindications and complications of ear wash. 10 
marks 

3. Give an account on: Fracture of the nasal bones Perforation of the nasal 
septum 

4. Give an account on Foreign body inhaled in the tracheobronchial tree. 20 
marks 



Fourth year otorhinolaryngology examination 

June fourth 2007 

time allowed 20 minutes 

Ansvver the follovving guestion: 

A 27 year old female was brought to the accident and emergency department 
having been involved in a car accident.Her mother,who had been with her,said 
that she was unconscious for 2 minutes then she gradually regained 
consciousness.However,she was complaining of sever headache,reduced 
hearing and a buzzing noise in her right ear. 



126 



On examination she was alert and gave a clear medical history.General vital signs 
were stable.There was no active bleeding but the right external auditory canal 
was full of blood.The left ear was normal.Weber test was lateralized to the right 
ear and Rinne test was positive on the left side and negative on the right 
side.Facial nerve was intact on both sides. 

1) Should the blood clot be removed from the right ear?Give reasons for your 
choice? 

2) What is the most probable diagnosis of this patient? 

3) What are the investigations needed to reah a final diagnosis? 

4) Describe the treatment of this condition? 



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Community Curriculum 
1. Overall Aims Of Course: 

The course is designed to introduce the student to: 

1. Graduate community oriented physicians capable of promoting physical, mental 
and social health. 

2. Use public health tools for prevention and control of health problems. 

3. Apply basic research tools to solve health problems and improve health systems. 

2. 1 ntended Leaming Outcomes Of Course (I LOS): 
1. Knovvledge & Understanding: 

At the end of the course students should be able to: 



1. Understand basic concepts of epidemiologic biostatistics. 

2. Understand quality concepts, people management, performance improvement. 

3. Know and understand basic concepts in environmental and behavioural medicine. 



2. IntellectualSkills: 

1. Definition identification, making priouts of public health 

2. Critical revievv of literatüre. 

3. Systemic approach of thinking 



problems. 



3. Professional & Practical Skills: 

1 L 

1. Apply appropriate health promotion, disease prevention and control measures. 

2. Identify behavioural and social variables impacting health and disease. 

3. Anticipate, assess and advise on management of occupational and environmental 
health hazards in various settings. 

4. General & Transferable Skills: 

1. Communication. 

2. Computer. 

3. Use of internet 

3. Contents 



Topic 

General epidemiology 
and methodology 
Child health 


No. of hours 


Lecture 


Tutorial/ Practical 


29 
94 


14 

43 


15 
51 


Adult health 


76 


35 


41 


Women health 


62 


10 


52 



129 



Occupational medicine 43 12 31 

Geriatrics health 25 15 10 

Total 329 hours 129 hours 200 hours 

4. Teaching & Leaming Methods: 

1. Lectures. 

2. Field visits. 

3. Şelf learning. 

4. Tutorial 

5. Student Assessment: 



Assessment methods: 



1. MCQ to assess Knovvledge. 

2. Short essay to assess Knovvledge. 

3. Oral to assess Knovvledge + attitude 

4. Practical to assess Skills. 

Assessment schedule: 



1. Assessment 1 Practical vveek variable. 

2. Assessment 2 MCQ vveek mid year (13-15). 

3. Assessment 3 Final vveek end of year (30-32 

4. Assessment 4 Oral vveek (30-32). 




VVeighting of Assessments: 

1. Mid year examination 20% . 

2. Final year examination 50% . 

3. Oral examination 20%. 

4. Practical examination 10%. 

5. Semester vvork % 

6. Other types of assessment % 

6. List of References: 

1. Coursenotes 

• Community, Environmental and Occupational medicine 

• Fourth year book. 

2. Essential books (text books) 

• Department book 

3. Recommended books 

• La Dou 

• Maxcy 

4. Periodicals, Web sites, .... Ete. 

• The vveb site of the department under construetion. 

• Other WHO sites, CDC sites, Süper course in epidemiology 



130 



7. Facilities Reguired ForTeaching And Leaming: 

1. computers 

2. data show. 

3. internet access. 

4. buses 

5. Lecture halis. 

6. Skill labs 



Child health 



1- list the diseases against which immunization is 1 st year of life in Egypt.describe the 
time schedule,methods of administration and material used for each one of them. 

2- describe the preschool mortality rate in Egypt . 

3- give an account on secondary prevention of maternal disorders in adolescent. 
4-in a nutritional survey out in a rural area among 10.000 primary school children. 
* list the possible deficiency diseases that can be found in such survey. 
*describe a program of prevention and control of these diseases. 
5-describe the epidemiology of Rickets in Egypt and its prevention. 
6- describe the epidemiology of PEM in Egypt . 
7-discuss the principles and elements of successful program of primary health çare 
(PHC). 

8-define "infant mortality rate" discuss the factors that determine the value of this rate in 

the community. 

9-list the elements of PHC and describe the supportive activities in such health çare 

system. 

10-describe the possible factors related to protein energy malnutrition(PEM) in Egypt. 

11 -discuss the objectives of PHC . 

12-give an account on health arrasial of school children. 

13-describe the strategy of implementing basic health needs in PHC 

14-define primary health çare ,describe the elements of basic health needs. 

15-give an account on infant feeding and proper methods of weaning. 

16-discuss the risk factors of malnutrition. 

17-describe the objectives and principles of school meal as an example of 

supplementary feeding programs. 



Woman health 



1 -discuss the goal and scope of family planning program in Egypt.2 

2-describe the relation between crude birth rate and infant mortality rate. 

3-discuss the measures taken by health centers to reduce morbidity and mortality from 

puerperal sepsis. 

4-discuss the causes of high fertility rate in Egypt. 

5- describe the measures used to estimate the population changes.discuss population 

problem in Egypt and compare with the developed countries. 

6-discuss the risk factors of developing cancer breast and prevention of this disease. 

7-discuss the epidemiology and prevention of obesity. 

8-define the maternal mortality rate discuss the factors that determine the value of this 

rate. 

9-describe the food balance sheet in Egypt. 

10-list the various types of nutritional aneamias in Egypt. 

-131- 



11-how can you calculate the maternal rate what's the importance pf calculating this rate. 

12-describe the characteristics of population pyramid in Egypt and their impact on health 

service planning. 

9) Give an account on HEALTH HAZARDS OF SMOKING . 

10)Discuss the risk factors of DEVELOPING CANCER BREAST & prevention of this 

diseases . 
11)Describe the epidemiology & prevention of OBESITY . 
12)Describe the risk factors of BRONCHOGENIC CARCINOMA . 



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Adult health 



1- discuss the risk factors of bronchogenic carcinoma. 

2-List food groups and describe the objectives of supplementary feeding programs. 

3-give an account on the pattern of Egyptian diet and its reflection on health. 

4-Give an account on health hazards of smoking. 

5-describe the prevention of cancer colon. 



6-define primary and secondary prevention of cancer base on current knowledge of 

risk factors,describe the primary prevention of disease. 
7-describe the measures to be taken to prevent DM 
8-discuss the preventive methods of bronchogenic carcinoma. 
9-discuss levels of prevention in rheumatic heart disease. 
10-Discuss the risk factors of ischemic heart disease. 



Occupational Health 



1) Describe the duties of FACTORY PHYSICIAN . 

2) Describe the prevention measures against HEAT DISORDERS . 

3) List the HEAR RELATED DISORDERS & discuss the prevention of one of them . 

4) Discuss the duties of OCCUPATİONAL HEALTH TEAM in glass factory . 

5) Write an account on health hazards of IONIZING RADIATION . 

6) Discuss the duties of OCCUPATİONAL HEALTH PHYSICIAN . 

7) Describe the role of INDUSRIAL PHYSICIAN in a factory . 

8) Describe the etiology, diagnosis & prevention of SILICOSIS . 

9) List the etiological factors of ACCIDENTS , describe the methods of prevention 

10) Discuss the prevention measures to workers exposed to IONIZING RADIATION 

-132- 



11) Discuss the prevention measures to workers exposed to NOISE . 

12) Write an account on health hazards of exposure to NOISE . 

13) List the OCCUPATIONAL LUNG DISEASES which are caused by exposure to 
cotton dust , discuss the prevention of one of them . 

14) Give short notes on one of either: 

* Goals of genetic counseling . 
OR , * Ethical issues in prenatal diagnosis . 

15) Describe the epidemiology of DECOMPRESSION SICKNESS . 

16) Write a notes on LIFE EXPECTANCY in Egypt . 




CoMMuNiTy 



1-ln July 1993, 200 cases of fever were admitted to fever hospital in Aswan, 

during the 

same period in 1991 and 1992 only 62 and 50 cases were admitted respectively, 

admitted cases in 1993 suffered from high fever with severe headache, Myalgia 

and 

Arthralgia, 20 of them complained of disturbance of vision and 50 died few hours 

after 

admission to hospital, the rest were given supportive treatment and were cured 

within 3 

to 5 days, cases included ali ages, both sexes and 70% of them dealt with 

animals. 

During the months of May and June 1993 a veterinarian noted increased 

incidence of 



abortion among cattle and death of camels. 

a- Calculate the case fatality rate, 

b- List the steps to be used to investigate outbreak. 

c- What are the possible differential diagnoses of public health importance of 

such an 

outbreak? 

d-Describe briefly the future preventive measures to be taken. 

2-Write an account on PERIODICAL MEDICAL EXAMINATION of industrial 

vvorkers. 

3-Describe the solution for the CURRENT POPULATION PROBLEM in Egypt 

4-Discuss the epidemiology and prevention of ENDEMIC GOITER as a public 

health 

problem. 

5-Discuss the levels of prevention of CHRONIC RHEUMATIC HEART DISEASE 

among 

school children. 

6-Discuss the HEPATITIS (B) MARKERS; describe the epidemiological 

significance of each 

one 

7-A 12 years old boy in a 1 ry school at Abassia district complained of sudden 

onset of 

irregular fever, malaise, nausea and vomiting, severe headache and muscle pain 

with 

stiff neck, the school physician suspected an epidemic of cerebrospinal 

meningitis. What 

are the measures to be taken for the boy, for his young brother (10 years old) and 

sister 

(8 years old) as well as his parents and his class room contact in the school? 

8-List THE HEALTH PROBLEM among the elderly population and plan a program 

for 

geriatric health services. 

9-ln a village of 800,000 inhabitants 32,000 live births were recorded in 1985, the 

recorded death in that year were (264 of them died in the f irst week) and 4544 

other 

persons including 200 stili births and 32 women who died because of post- 

partum 

hemorrhage and other causes related to pregnancy and labor. 

Calculate the other following vital rates in village in 1985; 

• Rate of natural increase of the population 

• Peri-natal mortality rate. 

• Maternal mortality rate. 



ALL ÛUSTIONS ARE TO BE ANSVVERED 

1) Enumerate the basic components of MATERNAL HEALTH PROGRAM & 
discuss the public health importance of PRENATAL INVESTIGATION. 

2) Write an account on the prevention of TETANUS NEONATOTUM. 

3) Write an account on the delayed effects of exposure to IONIZING RADIATION. 

4) İn May 1995 , 10 adults male visited the outpatient clinic to Ain-Shams hospital 
complaining of fatigue following minimal efforts , constipation & muscle 
weakness , on examination pallor was detected as well as a blue discoloration of 



134 



the gums ali of them worked in a nearby factory for manufacture of bottom , next 
day another worker for the same factory was admitted with severe abdominal 
colic , Discuss the possible diagnosis , investigation needed & describe 
measures to be taken for prevention . 

5) Discuss the epidemiology & prevention of IRON DEFICIENCY ANAEMIA in 
Egypt . 

6) İn a district of Ûalubia governorate , the population in 1994 was 180,000 
persons , 1980 death in ali ages & 5400 births were reported out of these births 
130,000 in the first year of life ( 160 died in the last 11 month of the first year of 
life) 

a- Calculate the rate of death . 

b- Calculate the neonatal mortality rate . 

c- Write short account on the risk factors of infant mortality in Egypt . 

7) 200 student joined a seaside summer camp at 7:00p.m. on Saturday 8th August 
1995 , at 8:00 p.m. they received a dinner of fish , shell fish , backed potatoes , 
green salad & watermelon , at 8:00a. m. next morning 50 students suffer from 
nausea , vomiting , diarrhea ,examination showed that they were drowsy & had 
fever of 38 C What is your provisional diagnosis? Discuss the steps to follow to 
investigate this situation. 

8)ln fayoum,the population in 1984 was 880.000 persons the reported new cases 

of TB was 7040 cases, in 1994 population was 1200 cases. 

a-compare the incidence rate of TB in 1984 to 1994 

b-discuss the risk factors to contact TB 

c-give an account on the methods of prevention of TB 

9) 200 students joined a seaside summer camp at 7.00p.m 

on Saturday 8-8-1990 at 8.00pm they received a dinner for fish,shellfish,backed 

potatoes,greensalad and watermelon.at 8.00am next morning 50 students suffer 

nausea,vomiting and diarrhea.O/E they are drowsy and had fever of 38 c.what is 

your provisional diagnosis?discuss the steps to follow to investigate this 

situation. 

10)Write an account on the health precaution to be taken for travelers coming 

from Zaire. 



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1-compare and contrast hepatitis M A M and hepatitis M B M as regard method of 

infection, prevention and control. 

2-write an account on health precautions to be taken for travelers coming from 

Zaire. 

3-discuss the prevention of schistomiasis in Egypt. 

4-list the disease transmitted by food bought by school children from street 

vendors.discuss methods of prevention. 

5-write an account on risk factors of sexually transmitted diseases. 

1996 

1- 8 years old child complained of fever 38 c for 2 days.on the third day ,he 

developed stiffness of the neck.what rae the measures would you take for this 

patient and his contacts at home and at school? 

2-give an account on: 

a)tetanus b)poliomyelitis 

3-compare the epidemiology,prevention and control of salmonella and staph 

areus food poisoning. 

4-discuss the prevention and control of schistosomiasis in rural areas of Egypt 

5-give an account on: 

a)chemoprophylaxis against malaria. 

b)international measures against yellovv fever. 



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136 



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ALL ÛUESTIONS ARE TO BE ANSVVERED: 

1) Why iron deficiency anaemia is the main nutritional problem in developing 
countries & what are the risk groups of iron deficiency anaemia? 

2) What are the components & objectives & comprehensive medical examination 
of school children . Give an account on the health records of the school children . 

3) Give the etiology of home accidents & how to be prevented? 

4) Discuss the possible etiology risk factors of cancer breast & its prevention . 

5) Write an account on the general outline of prevention of occupational diseases 

6) A survey was conducted by 5th year medical student to study the problem of 
smoking among new medical students (1st year) the questionnaire was prepared 
& standardized , the study include 500 students in the first year in Dec 1994 , one 
hundred student out of 500 were smokers at the beginning of the study , after one 
year of fellow-up of non-smoker i.e. in Dec 1995 the questionnaire was reapplied 
& the result showed that 120 students converted to smokers 
calculate the following : 

a) The prevalence rate of smoking in Dec 1994 . 

b) The incidence rate of smoking in Dec 1995 . 

c) The ratio of smoking in Dec 1995 . 

7) Last night your younger brother & son of your porter ( EL BAWAB) had been 
diagnosed to have typhoid fever , What are the control measures for each of them 
& their contacts & what are your preventive measures against typhoid fever? 

8) Discuss the investigation of PRE NATAL ÇARE & its significance . 

9) A 35 year old man was admitted to SHARM EL SHEIKH hospital with left 
hemiplagia he suffered severe pain in the right elbow these symptoms happened 
6 hrs after diving in the sea , Discuss management of the case & prevention of 
futu re attacks . 



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1) bilharziasis is a disease of national importance....describe this disease in 
Egypt 

2) discuss preventive measures taken for: 

a) 9 month old child his elder brother have measles 

b) travelers going to malarias areas 

3) compare the epidemiolodical features of: 

a) poliomyelitis in Egypt more developed countries 

b) an epidemic of cholera caused by El-Tor vibrio & that caused by classical 
cholera vibrio 

4) a 35 y. old man with 2 children under 10 y. of age presented with cough, night 
fever& sweating.. his tuberculin testing is greater than 10 mm in duration. You 
suspected him to have TB.. what are the different preventive & control measures 
taken foor this man & his family? 

5) what are the measure taken to decrease the risk of transmission of: 

a) hepatitis B virüs infection from pregnant female to her baby 

b) tetanus infection in a wounded child 5 y. Old 



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1) an Egyptian teacher is going to Af rica to work for two months.. he asked your 
advice. What are you going to teli & give him against malaria infection? 

2) what are the social & environmental risk factors associated with spread of: 
a) measles b)meningitis 

3) A 5 y. old child was playing with his neighbor's dog. He pulls his tail & the dog 
bit him in his right thigh. What are the measures taken if the dog is escaped? 

4) Mention 3 causes of bacterial food intoxication& give account on eoidimology 
of one of them & discuss how to investigate outbreak of food poisoning 

5) Write an account on: 

a) Importance & use of tuberculin test 

b) Prevention of AİDS 




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JUNE 1999 








1) Discuss the public health importance: 

a) Periodic medical examination of food handlers 

b) Tuberculin test 

2) Describe the epidemiological picture of poliomyelitis in Egypt compared to 
developed countries 

3) An 8 y. old child presented with fever, vomiting, neck rigidity & back pain. A 
lumbar puncture showed turbid CSF under tension he was diagnosed as a case 
of meningiococcal meningitis what are the appropriate control measure for the 
case & the contacts 

4) give an account on: 

a) prevention of neonatal tetanus 

b) hepatitis B vaccination ._ _ 

5)Egyptian engineer going to work in south of Sudan for 3 month what are 

the prevention measures taken before traveling &during his stay 

June 2000 

1) dicuss the cause of epidemology in our community 

2) advantage & disadvantage of cohort study 

3) descibe the epidemology feature of : 
a) typhoid fever b) measles 

4) describe the preventive measure for the following disease: 
a) hepatitis B b) chicken box 

5) describe situation of schistsomiasis in Egypt & discuss the prevention & 
control of this disease 

6) mention the source of infection & incubation period of tetanus & give a brief 
account on prevention & control 

6) Egypt considered a recipient area for yellow fever & write short on 
epidemology of yellow fever & the preventive & control measures in Egypt 



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June2001 



1) Mention: 

a) Risk groups in AİDS 

b) Mode of infection of anthrax 

c) Pre & post exposure vaccination against rabies 

2) Describe: 

a) The epidemiology of yellow fever 

b) Reservoir & mode of transmission of kala azar 

c) Distribution & recent prevalence rates of bilharzias is in Egypt 

3) Mention in short: 

a) Chemo prophylaxis of malaria 

b) Screening methods of diabetes 

c) 2ry prevention of genetic disorders 

4) Advice shortly how to prevent: 

a) Renal disease 

b) Coronary heart disease 

c) Cancer stomach 

5) Describe: 

a) Factors affecting mental health 

b)Protection of travelers to Mecca during pilgrimage 

6) Give a health education talk to the public about: 

a) Benefits of smoking cessation 

b) Sources & hazards of air pollution 

c) Main health problems among geriatric population 

7) Mention in a table: 

a) At lest 9 differences bet. Services offered by a hospital & that offered by 1 ry 
health çare units 



141 



b) Causative agent, exposed occupation & prevention of two ex. From bacterial, 
viral, parasitic& fungal occupational infection 

8) Mention: 

a) Advantage of breast-feeding 

b) Types of hospital waste 

c) Recent definition & causes of accidents 

9) Mention in a diagrammatic chart: 

a) Hazards of work place 

b) Asphyxiates & irritant gases 

c) General outline of prevention of occupational hazards 

June2002 

1-discuss in details the following: 

a)causes and prevention of work related stress (10 m) 

b)main health hazards among hospital workers (10 m) 
2-give short notes on: 

a)types,risk factors and prevention of sexually transmitted 

b)how to assess the maternal health services(4 m) 
3-give an account on: 

a)health hazards and diseases pattern among elderly population in 

Egypt(10m) 

b)risk factors and prevention of osteoporosis among women.(4 
4-discuss shortly: 

a)risk factors of ischemic heart disease.(10) 

b)mode of transmission and prevention of anthrax.(4 m) 
5-write an advisory talk to workers and managers of a factory about: 
a)short term benefits of stopping smoking(5 m) 
b)importance and economic value of occupational health(5 m) 
6-discuss briefly: (18 m) 
a)antioxidants. 
b)risk factors of childhood malignancy. 

cjhazards of lack of ergonomics. 

September 2002 



diseases(10m) 



İm) 

1 





1-discuss the following: 

a)common cause and symptoms of work related stress. 

b)main health hazards among hospital workers. 
2-give short notes on: 

a)indices for measuring the magnitude of pulmonary TB 

b)evaluation of family planning services. 
3-advice your grand parents about diet,vaccination and screeninig to be adopted 
for promotion of their health and prevention of disease. 
4-discuss shortly: 

a)coal workers pneumociosis. 

b)risk factors of DM 

cjmode of transmission of filariasis 
5-give an account on: 

a)role of school in improving nutritional status of school children. 

b)importance and economic value of ergonomics. 
6-discuss briefly: 

a)risk factors of occupational cancer. 

b)musculoskeletal disorders of occupational origin. 



142 



June2002 



1-a)discuss therole of epidemiology in our community. 

b)advantage and disadvantage of cohort study. 
2-describe the epidemiological features of: 

a)typhoid fever 

b)measles 
3-describe the preventive measures for the following: 

a)hepatitis A b)chicken pox(varicella) 

4-describe the situation of schistosomiasis in egypt,and discuss the prevention 
and control of this diseases 

5-mention the source of infection and the incubation period of tetanus.give a 
brief account on the prevention and control 

6-Egypt is considered a recipient area for yellow fever,write short account on the 
epidemiology of yellow fever and the preventive and control measures in Egypt 



i 




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September 2002 



1- give an account on recent definition and causes of work accidents. 
2-comment on the importance(indicative value)of : 

a)infant mortality rate. b)maternal mortality rate 

3-define the main health problems of elderly population 
4-write short notes on: 

-143- 



a)stages of behavioral changes and relapse 

b)objectives of family planning 
5-describe the prevention of: 

a)noise induced deafness. b)hepatitis A 

6-enumerate the types and causes of malnutrition 
7-write short notes on the epidemiology of rift valley fever 
8- enumerate the vaccination schedule for the first year of life. 
9-describe lines of prevention of the quaraninable diseases 
10-define the risk factors of hypertension. 



June2003 



1-write short notes on: 
a)hazards of smoking (10 m) 
b)risk factors for diabetes (10 m) 
2-write short notes on: 

a)specific preventive measures of meningitis (10 m) 

b)epidemiology and prevention of rickets (10 m) 
3-discuss briefly: 

a)complication of obesity (10 m) 

b)advantage of breathing (10 m) 
4-discuss briefly: 

a)prevention of silicosis (1 m) 

b)non-auditory effect of noise (1 m) 
5-a)what are the practical application of tuberculin test? (5 m) 

b)define maternal mortality rete and list the main causes of maternal 
deaths (5 m) 
6-define aging and discuss the prevention of accidents in elderly (5 m) 

define carrier and discuss its epidemiological importance (5 m) 



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144 



September 2003 



Write short notes on: 

preventive measures of measles (10 Marks) 

Epidemiology and prevention of protien energy malnutrition (10 Marks) 

Give short notes on 

Smoking cessation program (5Marks) 

Risk fators of hypertension (10 Marks) 

Discuss briefly 

Hazards of över population (10 Marks) 

Goals and objectives of family palnning (5Marks) 

Give short account on 

Prevention of asbestosis (10 Marks) 

Health hazards of ionizing radiation (5Marks) 

Write short notes on 

BCG vaccination (5Marks) 

Infant mortality rate and list the main Causes of Infant deaths (10 Marks) 

Give short notes on 

Health hazards among elderly (5Marks) 

Epidemiologic importance of incubation period (5Marks 

May 2004 ~ 




Give short notes on 

Health preservation of Aged persons 

Risk factors of childhood cancer 

Scope of family planning 

Mention the prevention and control of: 

Chicken pox b)Meningitis 

Give short notes on: 

Sanitary school Environment b)Analgesic nephropathy 

c)Health hazards among hospital workers 

Give your advice for protection of travelers to 

Cameron b)lndia 

Give short noteon: 

Causes and prevention of work related stress 

Health Effects of Noise 

Causes of occupational Accidents 






i 



c)Brucellosis 






c)Mecca 




September 2004 



1-Give short notes: 

a)Main health problems of aged persons 

b)Risk factors of cancer breast 

c)1ry health çare 

2. Mention the mode of transmision, prevention, & control of: 

a)Measles b)Rabies c)Brucellosis 

3.Give short notes on: 

a)Sanitary school enviroment b)Analgesic nephropathy 

c)Health hazards among hospital workers 

4.Give your advice for protection of travelers to: 

a)Nigeria b)Pakistan c)Mecca 



145 



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5.Give short note on prevention of: 
a)Work related stress 
b)Musculoskeletal disorders 
c)Occuptioal accidents 



May 2005 



AN questions are to be answered: 
LDiscuss the following: 

a)Aims & uses of epidemiololgy 

b)lmportance of notification of disease 

c)Uses of prediction models 
2.Mention the main lines of prevention of: 

a)Travelers diarrhea 

b)Rheumatic fever 

cjlnfluenza 
3.Give short notes on: 

a)Examples of occuptional parasitic infections 

b)Care for high risk child 

c)Natal & postnatal çare of HIV mother 
4-Discuss the prevention of: 

a)Work related stress 

b)Thalassemia 

c)Blindness 
5.give short notes on: 

a)Recent outbreaks during the year 2004 

b)Health related behavioral models 

c)General outlines for prevention of occuptional disease 
6.Mention in a table for the health hazards among hospital workers 

m 




September 2005 



LDiscuss: 
a)lmportance of antioxidants 

b)Health hazards after natural catastrophe of katrina in USA 
c)Uses of screening tests 
d)Main line of prevention of: 
*Yellow fever 
*Rabies 

*Work related stress 
2.Give short notes: 
a)DOTs strategy 
b)Polio eradication 

c)Occuptional & work related hazards among women 
d)Risk factors of : 

*Osteoprosis 
*Alzheimer s disease 
*Diabetic nephropathy 
3.Give short notes: 

a)National program of elimenation of Lymphatic Filariasis 



146 



b)lmportance of occuptional health on national development 
c)Non-auditory effect of noise 
4.Give an account on: 

a)Health hazards of ionizing radiation 
b)lmportance of school health program 
c)Causes of occuptional accident 

may 2006 




LProvide short notes on the following You can use diagrams for description): 
a)Role of community medicine throughout the health spectrum 
b)Components of health program for acertain group of population 

c)Fertility rates 
2.Discuss in short the the following: 
a)Types,causes & prevention of high attiude illness 
b)Cousling the mother in the integrated management of child health 
c)Health risk of child labor 
3.Comment on the following: 

a)Components & health effects of enviromental tobacco smoke(ETS) 
b)Nutriton for wokers in different exposures 
cjCommon causes & symptoms of work related stress 
4.Mention in short the followig: 

a)Benefits of the the application of ergonomics in the work places 
b)Occuptional health system in Egypt 

c)Occuptional exposure to Leptospirosis,toxoplasmosis & rubella 
5.Mention the prevention of: 
a)Meningoococcal meningitis 
b)lschemic heart disease 
c)Brucellosis 


september 2006 

"I.Give short notes on: 

a)Steps of outbreak investigations 
b)Poliomyelitis eradication in Egypt 

c)Riskfactors related to malnutrition 
2-Discuss the following: 
a)Risk factors of Leukemia 
b)Evidence that support the association between enviromental tobacco smoke & 
child asthma 

c)WHO classification for hospital waste 
3.Write an account on: 
a)lndication & health effect of air pollution 

b)Enviromental & Organizationl factors that associated with occuptional 
accidents 

c)Heat acclimatization 
4.provide short notes on: 

a)Main causes of morbidity & mortality among vvomen in the childbearing period 
b)Screening tests for elderly people 
c)Control of cholera 
5-Discuss in short the following: 
a)Prevention & control of Hepatitis B virüs infection 




147 



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b)Risk factors for chronic Renal Faliure 
cjlncideence & prevalence rates 



Community 

16/6/2007 

time:2 hours 



ali guestions are to be answered (9 marks for each) 

1) Discuss the specific measures of the prevention of the following diseases: 
a) Measles b) Typhoid fever 



2) Write an account on: 

a) Epidemic curve 
assessment 




b)Direct tools of nutritional 




3) Givea short noteon: 

a) Elements of safe motherhood 

b) Who recommendations for baby friendly hospital 

4) Mention the sources and the modes of transmission of the following 
diseases: 

a)Tuberculosis b)Chicken Pox c)Poliomyelitis 

mm 

5) Discuss the role of diet as risk factor for development of: 
a)Cancer b)Coronary Heart Diseases 



6) Give short notes on pathogenesis of: 
a)Silicosis b)Asbestosis 

■ 

7) Discuss the preventive measures of: 
a)lonizing Radiation b)Brucellosis 



8) What are the recommendations for prevention of avian influenza? 

9) VVrite an account on secondary prevention of: 
a)Hypertension b)Diabetes Mellitus 

10) Give an account on: 

a)Evaluation of geriatric health services b)Benefits of regular exercise 




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o^JaJl M4I | 


1. General Toxicology 


o Botulism fe 


2. Corrosives 


16.Animal poisoning p 


o Phenol 


o Scorpion sting y 


o Oxalic acid 


o Snake bite r 


3. Atropine 


o Spider sting P 


4. Pesticides 


17.Drug dependence and drug y 


o Organophosphorus 


abuse K 


o Carbamates 


o Opiates and opiate £ 


o Naphthaline 


dependence y 


o Rodenticides 


o Cannabis y 


o Zinc phosphide 


o Amphetamine fe 


o Anticoagulants 


o Cocaine y 


5. Alcohols 


^^^^^^ o Tobacco smoking y 


o Ethyl alcohol 


(Nicotine) fe 


o Methyl alcohol 


o Volatile abuse p 
o Benztropine abuse p 


6. Hydrocarbons 


o Kerosene 


o Dependence by sedative | 


7. Heavy metals 


hypnotic drugs p 


o Lead 


o Alcohol dependence y 


o Mercury 


18. Role of laboratory in clinical | 


o Iron 


toxicology p 


8. Psychotropics 


v ^U ^ 


o Neuroleptics 




o Antidepressants 


Forensic medicine curriculum y 


o Tricyclic antidepressants 
o MAOI 


1. Medical ethics | 


2. Identification p 


o New antidepressants 


3. Diaanosis of death £ 


n r,°, Llt î lüni , 4. Sudden natural death K 


9. Sedatıve hypnotıcs 
o Barbiturates 


5. Postmortem changes p 

6. General vvounds p 


o Benzodiazepines 
o Meprobamate 


7. Injury of special organs | 

8. Causes of death from vvounds | 


o Chloral hydrate 
o New sedatives 


9. Head injuries p 




lO.Firearm injuries y 


lO.Analgesics 

o Salicylates 
o Paracetamol 

ll.Theophylline 


ll.Asphyxia | 
12. Physical injuries p 
13. Transportation injuries y 
14. Blood stains | 


12.Cardiovascular drugs 
o Digitalis 
o Beta blockers 


15. Diagnosis of pregnancy | 
16.Delivery p 
17.Abortion y 


13.Anticonvulsants 


18. 1 nfanticide | 


o Phenytoin 


19.Sexual offences p 


o Carbamazepine 




14.Toxic gases 




o Carbon monoxide 




o Cyanide 




o Hydrogen sulphide 




o Other gases 




15. Food poisoning 





150 



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Forensic medicine 



(A) HEAD INJURIES. 



1 .discuss meningitis after trauma? 

Differentiate between coma due to concussion and alcohol? 

3.discuss cerebral compression after head injuries? 

4.discuss incised and contused wound of scalp? 

5.describe cut fracture of skull vault? 

6.describe fissure fracture of skull vault? 

7.discuss sequel of concussion? 

8.discuss types and severity of vault fracture? 

9.enumerate &define the different types of head injuries &describe clinical picture, 

management & complication of one of them? 
10-discuss fracture base of the skull? ^^^ 
11.give an account of lucid interval and its medico legal importance? 



(B) Death & P.M picture. 



Ldiscuss the early diagnostic sign of death ?give an account on hypostasis 

&differentiate between it and contusion and medico legal importance ? 
2.enumerate sudden death in relation to C.V.S ? 
3. give an account on somatic and molecular death ? 
4.how would you certify the time of death within 1 st 24hrs ? 
5.discuss factor influencing the rate of putrefaction? 

6. discuss cadivic spasm ? 

7. discuss medicolegal importance of adipcere formation ? 




(C) VVOUND. 



1. discuss examination of abrasion? 

2.how would you certify a case of criminal wounding as one of simple injury only? 

3. Give an account on puncture wound? 

4.how would you determinate age of concussion [bruise]? 

5.discuss death from reflex vagal inhibition? 

6. Give an account on embolism as a cause of death in wound? 



(D) BLOOD 



1- Give short account on takayama test . 

2.give a short account on teichman test ? 

3.give a short account on medicolegal importance of blood grouping ? 

4. in medicolegal report, the examiner stated that, there was dry blood stain on the 

ground belonged to the assailant and the group was AB .how did the examiner arrive 

to this result ? 
5.discuss the blood transfusion incompatibility? 



(E) IDENTIFICATION 



"l.you were asked to a certification concerning the age of 
* A young female about to get married. 
*A young male in order to obtain his legal rights. 
How to estimate their age? 

2. What is importance of hyoid bone? 

3. How you can diagnosis the age of dead full term baby? 

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(F) BURNS &PHYSICAL İNJURİES 



151 



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Ldiscuss cause of death after burns ? 
2.discuss death by electricity ? 
3.discuss heat hyper pyrexia ? 
4.discuss factors affecting gravity of burns ? 



(G) ABORTION &PREGNANCY 



1. what are the complication of criminal abortion ? 

2. give short account on criminal abortion? 

3. write an account on violability of infant? 

4. write an account on umbilical cord examination ? 

5. how you can diagnosis a dead full term fetus ? 

6. what the medico-legal importance of examination of foot of newly born infant ? 

7. what is medico-legal importance of umbilical cord around neck ? 



(H) RAPE 



Ldiscuss consent in rape ? 
2. discusssodomy ? 
(I) Asphyxia 
Lmention the importance of hydrostatic test ? 

2. what is meant by hanging? MENTION the causes of death ? 

3. how would you prove ligature mark of a rope around the neck is due to hanging or 

strangulation ? 
4.give an account on the lung in death due to drowning ? 
5.discuss postmortem finding in case of hanging? 

6. discuss sure signs of death from drowning ? 

7. discuss the postmortem picture of throttling ? 

8. a child 6 years was strangulated by a rope ,the body was examined after 12 hrs 
*how can you identify the age of child ? 



*what is the P.M picture? 

9. how can you differentiate 

from point ? 



between a hanging point of suspension and hanging 



(J)FIRE ARM 

Lmention the importance of powder marks ? 
2.how would you differentiate whether a case of fire arm injuries ? 
3.give an account on internal wad ? 

4.how would you estimate the distance of firing in sporting injuries of fire arm 
5.discuss characters of fire arm injuries ? 

6.describe the inlet of gun shot that would be from a distance of 4 meters? 
8. discuss character of point blank fire arm injury ? 

9.on medicolegal report , the examiner stated that ,the victim sustained a fire arm injury 
by a short gun in the right thigh, fined at a distance of 2 meters . how did the 
examiner reach to this result ? 



MEDICAL ETHICS 



1. what are circumstance under which a medical practitioner should disclose 
professional secretes ? 

2. discuss consent of treatment by operation ? 

FORENSIC CASES 
1. in medicolegal report the examiner tested that the victim is a 
female 23 years old .she is pregnant ,the period pregnancy is 24 
weeks &the cause of death is manual strangulation .how did the 
medical examiner arrived to this condition 
2. in a medicolegal report the examiner stated that : 



152 



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the victim is a female 16 years old ,she was rapid then stepped by a sharp 
instrument in the neck chest & abdomen then cadaver has been BURNED to 
cancel the erime .how did the medicolegal examiner reached to these conelusion 

3. a 25 years old female report to the poliçe station &presented that during quarrel , 

the neighbor kicked her in abdomen &she alleged that she aborted after 16 weeks 
pregnaney &she presented certain flesh in a piece of eloth & alleged that the flesh 
is the produet of abortion . the women has been referred to you to examine her 
&the flesh &to write a medicolegal importance ? 

4. a40 years old man was found dead with a cut throat ,the medicolegal expert arrived 

3 hrs after death and stated that ,it was a homicidal cut throat. 

A) how did the medicolegal expert prove that it was a homicidal cut throat ? 

b) how can you identify the age of the victim ? 

c) how can you prove that the postmortem interval was 3 hrs ? 

d) mention the cause of death in this case ? 



TOXICOLOCY 



C o rro s ives 



! 



1- Give short account: on clinical picture ofpoisoning by oxalic acid. 86 

2- Discuss the squeal of KOH poisoning. 88 

3- Management of oxalic acid poisoning. 89 

4- Give a short account on treatment of a child who swallowed potassium hydroxide 
(potash). 94 



Insecticides 

What are the common types of chlorinated inseeticides? Discuss the clinical 

picture of one of them. 90 

Give short account on naphthalene toxicity. 87 

Give an account on chlorinated inseeticides. 93 

Give an account on the clinical picture and treatment of organophosphorus 

inseeticides. 95 

Discuss naphthalene toxicity. 95 

Management of a case of Naphthalene poisoning. 96 






Gas poisoning 



The clinical picture of CO poisoning & management. 90 

What are types of red asphyxia? What is the Mechanism (Inch)? 90,91 

Give a short account on management of cases of CO poisoning. 92 



Plant alkaloids 



The clinical picture & treatment of acute opium poisoning. 91 

Discuss the clinical picture and management of intoxication with Digitalis 

preparations. 96 



Metals 



1- Give an account on EDTA. 87, 89 

2- Clinical picture & management of Fe toxicity. 88 

3- The clinical picture in case of mercurism. 92 

4- Give a short account on iron toxicity. 94,95 

5- Discuss the clinical picture and management of indication with ehronic lead 
exposure. 96 

6- Give an account in İron toxicity. 97 

7- Discuss Treatment of İron toxicity. 98 



Drug abuse & dependance 



1- Write short notes on disulfiram (antabuse). 85,86 

2- Discuss physical & emotional dependence to. drugs with examples. 87 

3- Discuss the ttt of acute salicylate poisoning. 87 

4- Describe the ttt of acute barbiturate poisoning.88 

-153- 



Give an account on cocaine dependence. 86 
Discuss management of acute salicylate poisoning. 86 
Narcotic competitive antidotes. 86 
Discuss the heroin addiction, clinical picture, 
management & prognosis. 88 
Give an account on digoxin över dose. 89 
Discuss lines of treatment in poisoning of tricydic antidepressants. 90 

Discuss the effect of salicylate 90 

Give a short account on acute toxicity tricydic antidepressants. 93 

Give a short account n diagnosis of heroin dependence. 94 

Give an account on treatment of acetaminophen (paracetamol) poisoning. 95 

Discuss the medical hazards of drug dependence-95 

Treatmentt of acetaminophen (paracetamol) poisoning. 96 

Physical and emotional (psychic) dependence. 96 

Give an account on ttt of salicylate toxicity. 97 

Biotoxins : 
Describe lines of treatment in poisoning by scorpion stings in the foot. 87 

Clinical picture and treatment of scorpion stings. 98 

General toxicity & managment 
Mention on brief the importance of EDTA. 89 
Discuss the indications & contraindication of gastric lavage. 89 
Give short account on naloxone. 90,92 
The physical antidotes (5 marks) 92 
Give an account on Naloxone. 93 
Discuss contraindications of gastric lavage. 95 
Discuss chemical antidotes. 98 



Toxicoloqy cases 



1-D.D in a case of comatosed patient with pinpoint pupil 

2- the poison control center received an adult during examination, the physician 

noticed yellow discoloration of sclera in both eyes what are the most D.D and 

management of such case? 
3-a 25 years old male has been admitted to the poison control center, suffering 

from tachycardia. Enumerate the toxins that cause tachycardia. Discuss the 

mechanism of action of 2 of them and management in each of them. 
4-a 28 years old male has been admitted to the poison control center, suffering 

from acute pulmonary edema, the mechanism of action of each one and 

management in each case. 
5-enumerate the causes of toxicological coma and management of 2 of them. 
6-a 25 years old male has been to the poison control center, suffering from 

tachycardia. Discuss the mechanism of action of 2 of them and the 

management in each case. 
7- a 20 years old female has been admitted to the poison control center, suffering 

from bradycardia .enumerate the toxins that cause bradycardia and discuss 

the mechanism of action of 2 of them and management in each case. 
8-an adult male has been admitted to the poison control center with 

convulsions.what are the D.D and management in this case. 

9- a child swallowed the contents of a small bottle of a brown fluid ,used as a local 

antiseptic.he complained of burning pain,colic and the vomitus was yellow and 

its small was identified by the mother. 

a)what is the poison?give the rest of clinical picture. 
b)how can you treat his child? 
10-an adult male has been admitted to the poison control center with 

convulsions.what are the D.D and management of this case. 



154 



FOrEnSiC & ToXiCoLoGY 



Answer ali questions: 

1-A cadaver of a male aged 60 years was recovered from the river. The 

medicolegal 

report excluded drowning as a cause of death and stated that death was due to 

manual 

strangulation (Throttling). How did the medicolegal expert arrive to these 

conclusions? 

2-A 25 years old male has been admitted to the poison control center, suffering 

from 

tachycardia. Enumerate the toxins that cause tachycardia; discuss the 

mechanism of two 

of them and the management in each case. 

3-Give a short account on: 

* Criminal abortion. 

* Traumatic meningitis. 

* Naloxone. 

* Chlorinated insecticides. 




i 




AN questions are to be answered: 

1-The forensic expert stated in his report that the male victim was about 40 years 

and 

was shot in the face by a shotgun at the distance of three meters. The body was 

partially 

burnt after death to conceal the erime. How did the medicolegal expert arrive at 

this 

conelusion? 

2-Give short account on; 

* The legal necessities for the diagnosis of pregnaney. 

* Estimation of the age of a contusion (bruise) 

* Ligature mark around the neck. 

3-An adult male was admitted to the poison control center suffering from 
convulsions. 

What are the possible lexicological causes and management of this case? 
4-Give short account on: 

* Iron toxicity. 

* Diagnosis of heroin dependence. 

* Treatment of a child who swallowed K-OH (potash). 




155 



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AN questions are to be answered: 

1) A 40 years old man was found dead in his bed with a cut throat. The 
Medicolegal expert arrived 3 hours after death and stated that it was a homicidal 
cut throat. 

* How did the medicolegal expert prove that it was a homicidal cut throat? 

* How can you identify the age of the victim? 

* How can you prove that the postmortem interval was 3 hours? 

* Mention the causes of death in this case. 

2) Give an account on: 

* Burning by boiling water. 

* Characteristics of point blank firearm injury. 

* The medicolegal importance of lucid-interval. 

3) Give on account on: 

* The Cl/p and ttt of organophosphorus insecticides. 

* Treatment of acetaminophen (paracetamol) poisoning. 

* Iron toxicity. 

4) Discuss: 

* The medical hazards of drug dependence. 

* Contraindications of gastric lavage. 

Naphthalene toxicity. 



156 



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1996 






AN questions are to be answered: 

1) Discuss the following 

* Application of DNA typing forensic medicine. 

* The medical consent. 

* The examination of seminal stains. 

* The complications of criminal abortion. 

2) Give an account on: 

* Concussion, its clinical picture and forensic pathology. 

* Medicolegal importance of abrasions. 

* Mechanism and medicolegal importance of cadaveric spasm. 

3) Discuss the clinical picture & management of into intoxication with: 

* Chronic lead exposure. 
Digitals preparations. 



4) Give an account on: 

* Treatment of acetaminophen (paracetamol) poisoning. 

* Management of a case of Naphthalene poisoning. 

* Management of a child who ingested kerosene. 

* physical and emotional (psychic) dependence. 



1997 



A- FORENSİC MEDİCİNE 
1- Give an account on: 

a) medical consent. 

b) concussion , its cl.p. & forensic pathology. 

c) immediate cause of death from wounds. 



157 



d) heat stroke. 

B- TOXICOLOGY 

2- A 20 years old female has been admittedto the poison control center , suffering 
from bradycardia , enumerate the toxins that cause bradycardia . Discuss the 
mechanism of action of 2 of them & the management of each case . 

3- Give an account on: 

a) iron toxicity 

b) treatment of kerosene poisoning. 

c) treatment of salicylate poisoning. 





Y 



1998 



ALL ÛUESTIONS ARE TO BE ANSVVERED: 

1- Enumerate the cause of toxicological coma, and management of two of 
them. 

2- Discuss: 
a)Clinical antidotes. 

b) Treatment of kerosene poisoning. 

c) Treatment of iron toxicity. 

3- Discuss: 

a)clinical picture and treatment of scorpion stings. 
b) lucid interval. 

4- Discuss diagnosis of death. 



i 



Ju ne 1999 



1) Give a full account on: 

a) Medico legal application of dna in forensic medicine 



158 



b) Medico legal importance of lucid interval 

c) concet in rape 

2) Discuss: 

a) Characters of firearm injuries 

b) Complication of criminal abortion 

c) Scorpion sting 

3) Enumerate drugs & poisons causing bradycardia & discuss one of them 

4) Discuss: 

a) # of gastric lavage 

b) ttt of iron toxicity 



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1) A 6 years old child was extracted dead after a fire in a crowded cinema. On 
post mortem examination the medicolegal expert concluded that death was due 
to parasympathetic shock and that the burn seen in his body and cloth were 
postmortem 

a) How did he prove the age of the child was 6 years? 
b)explain the mechanism for the mentioed cause of death ? 

c) what are the postmortem finding that confirm the diagnosis? 

d) what are the postmortem finding that exclude the postmortem finding that 
exclude the antemortem Burn and confirm the postmortem one 

2) Give a short account on: 
a)different forms of medical consent 

b) sign of brain stem death 

c) manifestation &cause of death in incompatible blood transfusion 

3) A- gives a short account on cardio-pulmonary resuscitation. 
B-what is the treatment of acetaminophen poising. 

-159- 



C-how can you differentiate between botulism and salmonella food poisoning? 
4) A female child was brought to poison control center after local application of a 
pesticide solution to her scalp by her mother. Arrival follovving clinical finding... 
Pulse: 58/min &respiration 12/min &drowsiness & pin point pupils 

a) What are the tow possible group of pesticides causing such presentation ? 

b) By investigation how can you differentiate between the tow type of pesticide 
such presentation? 

c)What are coetaneous neuron-muscular and respiratory manifestation in such 

cases? 

d) how can treat this case. 



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June2001 



1-A 21 years old man was admitted to the emergency room in a drowsy st to and 
a wound in the scalp after a blow to the head. The wound was sutured and the 
patient was discharged 4 hours after admission 24 hours later he as readmitted in 
coma, hypertension, and unequal pupils. 
*Verify the age of the patient by doing X-ray. (one site). 
*How can you verify if the scalp wound was cut or contused? 
*Mention the sequelae that happened between the first and second admission. 
*What is the legal responsibility of the doctor who discharged the patient on 
the first admission? 
2-Give an account on: 



160 



a)Ligature mark in hanging. 
b)Characters of injuries in the battered child. 
c)Examples of negligence in malpractice. 

3-A farmer was found unconscious in his farm. He had repeated vomiting 
diarrhea and abdominal colic. On examination he was in grade III come, with pin 
point pupils, muscle twitches and crepitating ali över the chest. 
*What are the criteria of grade III coma? 
*What is the general treatment of a comatosed patient? 
*What is your proper diagnosis? Why? 
*What is the specific treatment in this case? 
4-Give an account on: 
*Medical hazards of drug abuse. 

"Treatment of acute acetaminophen (paracetamol) toxicity. 
*Clinical picture of acute digitalis toxicity. 



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June2002 

ALL ÛEUSTIONS ARE TO BE ANSVVERED (TIME:2 
1-Give full account on the following: 

a)medicoligal importance of hypostasis. 

b)ethics of gene therapy 

cjheat hyperpyrexia and exhaustion. 
2-in a rural area a medical practitioner was called to examine a body to give a 
death certificate.after external examination the physician reported the authorities 
that the body belongs to a child of 7 years old who was been shot from a non 
rifled weapon from a distance of about 4 meters and the suspected this body 
might be recovered from water. 

a.explain how the physician has reached his diagnosis abou the age,type of 
weapon,distance of firing and possibility of recovering the body from water. 
b.what are the possible causes of death in such a case.describe the external 
post-mortem picture of one of them . 
3-give a full account on: 
a.complications of corrosive ingestion. 

b.doses,contraindications and complications of activated charcoal. 
c.clinical picture of tricyclic antidepressant. 

4-a family of 4 persons was brought to the emergency room by an ambulance 
from home at night.3 of these patients gave history of vomiting several 
times,dyspenea and complaint of sever weakness.the fourth one was a child in 
state of coma with tachypnea and his ECG showed evidence of cardiac 
arrythmias and his face was red in colour 
a.what's the possible cause and mechanism of intoxication. 
b.what are the possible arrythmias present in such case ,explain. 
c.explain why the child developed more severe manifestations. 
d.discuss the line of ttt in such case. 



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September 2002 



Forensic medicine: 

1-give full account on: 

a.medicolegal importance in diagnosis of death. 

b.fabricated vv self inflicted wound" 

c.medicolegal aspects of organ donation from a living person. 

2-a medical practitioner is requested by local authority to give a preliminary 

report about a cadaver discovered in district,after external examination, he 

reported that it belongs to a female of about 16 years old.his report included the 

presence of a pale areas of hypostasis on the back with marked muscle stiff ness 

in head,neck,and forearm.scattered areas of abrasions and contusions on the 

nack were seen.yellowish discharge was noticed from nipples and red discharge 

was covering the genital areas. 

a.estmate the approximate time of death from available data. 

b.what is medicolegal significance of the discharge observed in this case. 

c.discuss possible causes of death in this case. 

d.what are the expected internal findings that could be seen during autopsy to 

confirm the cause of death. 

Clinical toxicology 

3-give full account on: 

a.clinical picture and ttt of scorpion sting. 

b.manifestations and pathophysiology of phenathiazine toxicity 

c.cardiopulmonary resuscitation. 

4-a 3 years old child was brought to the emergency room by his mother,she 

discovered him restless,agitated with difficulty in breathing.she found beside him 

empty container of her medication previously prescribed to lowe her 

temperature.O/E the child was restless,exctited with evidence of respiratory rate 

28/min and temperature 39° c .he developed cutenous purpuric rashes 24 hours 

after admission. 

a.wht's the drug responsible for this case.what are the diagnostic clues present. 

b.explain the respiratory,cutenous and temperature abnormalities,and their 

pathophysiology. 

-162- 




c.vvhat are the diagnostic intervention(investigations)indicated. 
e.hovv can we treat this case. 



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1-a 21 years old male was accused of strangulation of a 16 years old female after 

raping her.a bite was found on the assailant's shoulder. 

a)verify the age of both the victim and assailant by doing x-ray(one site for each 

age) (4 m) 

b)describe a recent tear in the hymen. (4 m) 

cjdescribe the ligature mark in strangulation (6 m) 

d)what are the type of injuries that could be produced by abite?write procedures 

for examination of bite mark. (10 m) 

2-Give an account on: 
a)diagnosis of a battered child. (8 m) 

b)causes of atypical appearance of the inlet in firearm injuries. (12 m) 

3- a clear fluid with a characteristic smell(used as fuel by poor people) was 

accidentally drunk by a child.when transmitted to the hospital he was drowsy 

with dyspnea and fever.crepitations were heard över the chest,x-ray was done. 

a)what's the suggested toxic agent in this case? (2 m) 

b)what's its effect on the lungs? (8 m) 

c)ttt of this case. (1 m) 

4-Give full account on: 
a)poison prevention strategies. (12 m) 

b)antidote for scorpion sting: indications and dose. (8 m) 

cjclinical stages of paracetamole(acetaminophen) toxicity.(10 m) 



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1 . A 23y old hit a 40y old man by a stick on his head . Some hair was found on 
the stick. The victim was transmitted to hospital in drowsy state,X-rays head 
revealed a linear (fissure)fracture and extradural hemorrhage.Few hours later full 
signs and symptoms of compression were noted. 

a) Verify the age of both the victim and the assailant by doing X-ray (one site 
for each age) (4 Marks) 

b) What caused this extradural hemorrahage? (6Marks) 

c) What is the C/P of cerebral compression? (10Marks) 

d) Discuss The medicolegal importance of examination the hair present on 
the stick (10Marks) 

2. Give full account on 

a) Forms of consent (6Marks) 

b) Compare between heat exhaustion and heat hyperpyrexia (14 Marks) 

3. After suicidal attempt,A female student was transmitted to the hospital with 
consticted pupil, sweaty face,vomiting,diarrhea,salivation, generalized weakness 
and muscle fasciculation.Crepitations were heard allover the chest 

a) What is your most probable diagnosis? (2Marks) 

b) How do you correlate the signs and symptoms to the mechanism of action 
of the suspected poison? (8Marks) 

c) Discuss treatment of the case (1 5Marks) 

4. Give a full account on 

a) Effect of salicylate overdose on respiration&acid-base balance (1 OMarks) 

b) Picture of Chronic tobacco somking (5Marks) 

c) Naloxone(Narcan)as an antidote for acute opiate overdose (1 OMarks) 



164 






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1- The medicolegal expert on examination of a cadaver of agirl reported that 

she is of 12 years old and having an antmortem deep cut injury by a corrugated 

instrument crossing the anterior surface of neck from side to side . The victim 

has been also seually assulted before death . the body has bluish nail bed and 

mucous membranea >. From the previous information : 

a- Discuss identification of the age ( one reason ) 

b- What are the reasons that leads to description of the wound by the 

medicolegal expert ? 

c- What are the posible causes of death ? 

d- Describe local findings that support the evidence of recent rape act . 

e- What are the samples to be taken from the victim that may help identifing 

the assai lent ? 

2-A- How do you defferentiat by TWO character only between : 

1 . Heat exahusted hyperpyrexia . 

2. İnlet of near firing up to 15 cm and 1 meter distance in non rifled weapon . 

3. Lucid intrval and early (irriative ) stage of intracranial comeression . 

4. Primary and secondery flaccidity 

5. High and low point of suspention . 

B- Give an account on duty of docotor in wounding cases . 

3- G ive an acount on : 

a. Pathophysilogy of methanol toxicity . 

b. Cardiopulmonay reucitation . 

c. Investigation and follow up of corrosive intke . 

4- A child of 4 years old ingested iron tabletd of his bregnant mother .He was 
brought to the hosbital after 2hours of ingestion with pain inn his stomach and 
history of twice bloody vomitus .On examination he was lethargic . After gastric 
lavage the child was improved and discharged . He returned back aftertwelve 
hours suffering from fever ,shock & jaundice . 

1. Enumurate 3 medication causing gastric bleeding after overdose . 

2. Explain the reasons of manifestations after discharge . 



165 



3. What are investigations to diagnose and evaluate the condition ? 
What are the emergancy lines of treatment inn such a case ? 



septemper 2004 



"l.the medicolegal report of examination of a male cadever included that, he is 23 

years old , died sice three hours . the victim has bean hit(beaten) by ablunt object 

on extremities about three days before death . the wrists and ankles showed 

recent traces of rough rope mark. a parchment like circular area was found in the 

lower part of tyhe right side of the chest . 

a)give one reason for identificaTlON OF THE AGE . 

B)WHAT ARE THE FINDINGS TO APPROXIMATE TIME OF DEATH . 

C)HOW COULD THE EXPERT ESTIMATE THE AGE OF WOUNDS INFLICTED ON 

THE BODY? 

d)enumerate possible causes of death. 

ejdescribe post-mortem picture of one of the causes . 

2. 

a)hwo do you deffrintiate by two properties only: 

i.internal and external wad of non rifled weapon. 

ii.antemortem and post mortem stabbing. 

iii.traumatic and meningococcal meningitis. 

iv.respired and non respired lungs of a newly born. 

v.thermal and traumatic skull fracture . 

b)mention the condition in which the practitioner is allowed to disclose the secret 
of tyhe patient. 

3.in suicifdal attempt a 20 year old female was brought to emergency room , after 
an hour of intake grand mother's cardiac therapy . she complained of nausea , 
vomiting blurring of vision and abnormal colour perception of yellow halos ,on 
examination :bl.p. 90/60mmhg,pulse 50beat/min. 

a)what is the most probable diagnosis. 

b)enumerate other three cardiotoxic agents . 

c)what are trhe investigations needed to asses and confirm the diagnosis . 

d)explain electolyte change obtained 

ejdiscuss treatment in sush a case . 
4.give full account on : 

a)complication of gastric lavage . 

b)clinical picture of acute carbon monoxide poisoning . 

cjblood picture in chronic lead poisoning . 





may 2005 



ali questions are to be answered : 

1.a newly born live-born baby was found dead in the street beside a building . the 
forensic examiner could know how long the baby lived after delivery from 
external changes that were present around the base of the umbilical cord .also 
burns by applying boiled water on buttocks and lower limb were noticed. the 
foremsic examiner reported that the baby was killed by throttling . 

a)describe the external changes that occur on the base of the umbilical cord 
and help to know the peiod of life after delivery. 

b)what is the type of burn caused by boiled water ?what are its characters ? 



166 



c)mention special features (neck signs) of throttling ? 
2.give full account on : 

a)ethics of donation of organ from a living person. 

b)medicolegal importance of countre-couplesions of the brain . 

cjcauses and medicolegal importance of persistant vegitative state. 

d)cause of large inlet in firearm injuries . 
3.a heavy smoker was found unconscious in the bathroom . he was in coma III 
and his skin and mucous membrane were pink in colour . chest examination 
showed pulmonary edeama . 

a)what is the probable causetive toxic agent? 

b)what are the crireria of coma III? 

c)what are the factors that affect toxicity with suspected agent? 

d)discuss treatment of the case . 
4.give full account on: 

a)clinical picture of botulism . 

b)specific antidot for digitalis toxicity. 

c)meshanism of respiratory tract and lung injury in kerosene toxicity . 

d)contra-indication of multiple dose activated charcoal(MDAC). 



1.A BODY WAS RECOVERED FROM THE RIVER . ON POST MORTEM 

EXAMINATION , THE MEDICO LEGAL EXPERT REPORTED THAT ,IT BELONGED 

TO A MALE person aged 21 years , multiple cut wounds ali över tyhe body were 

found and death was due to heamorrhage not due to drowning . explain how the 

expert reached the diagnosis about : 

a)age of the victim (by doing x-ray on one site only). 

b)type of injuries found on the body . 

cjthe victim was thrown in water after death (by external examination only). 

d)the cause of death. 

2. 

a)mention two medicolegal iportanceonly for the following: 

i.hypostasis. 

ii.dna typing application. 

iii.types of hymen. 

iv.lucid interval. 
b)give a short account on : 

i.ethics of gene therapy. 

ii.rapid causes of death from burns. 
3.a 28 years old farmer was found comatosed in his farm after ingestion of a clear 
fluid.he had been brought to the emergency department. on examination , he was 
found in grade II coma .pupils wera constricted , the pulse was 
50beats/min.,bl.p.90/60mmhg,and there was crepitations ali över the chest. 
a)what is the possible diagnosis of the case and why ? 
b)what are the criteria of grade two coma? 
c)how can you invistigate this case ? 

4.what are the general characters and genberal management of drug dependance 
? 

5.pathogenisis (pathphysiology)and antidotes in toxicity by: 

a)methanol. 

b)scorpion sting. 



167 



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c)b-blockers. 



septemper 2006 



ali questions are to be answered : 

a person recieved a trauma by a heavy blunt object on his right temple and fell on 

the ground unconcsious . on arrival to the hospital afterl hour , he was stili 

comatosed . his blood pressure was 150/90,pulse 50 beats/min. and resoiration 

was deep and slow . the pupil of the right eye was of normal size while that of the 

left one was dilated . 

also flaccid paralaysis of the rightside of the body occurred .he died at last . 

a)mention the possible diagnosis of the case . 

b)explain the mechanisms that lead to shanges of clinical picture . 

c)mention hwo could you identify the site of lesion by clinical examination . 

d)explain the pathophysiology of occurrence of the lesion at the affected site. 

e)mention the meshanism that lead to death. 

f)enumerate postmortem picture of this case . 

2.a) diffrentiate between the folowing three characters only: 

1-dry and wet burn. 

2-homicidal and suicidal cut throat. 

3-primary and secondary flaccidity. 

4-permanent and milky dentation . 

5-typical and atypical firearm inlet. 
3.a child was to the emergency room, presented with a bloody vomitus after 
ingestion of a coloured tablets of his pregnant mother . on the second day there 
as marked improvement of his condition . 

a)mention four toxilogical causes of bloody vomitus? 

b)does the improvement in his condition allow the physician to discharge 
the child from hopspital? 

c)explain the expected clinical picture of this case . 

d)how could you manage this case ? 
4. 

a)mention the pathophysiology of acyte poisoning by the following poisons and 
their antidotes 

i.digitalis . 
ii.scorpion sting . 
iii.opiates . 
b)discuss breifly the complications of corrosve burn. 





Forensic Medicine& Clinical Toxicology 

24/6/2007 

time allawed 2 hours 



ali guestions are to be ansvvered: 

1) A divorced female, 18 years old ,brought her 2 years old child to the 
emergency room complaining of scalp injury. She told the doctor that her 
child hit the wall while running. On examination the physician found a 
bleeding contused wound in the scalp, two contusions of 3 an 7 days old on 
his right thigh, abrasions on his back, and human bite marks of different ages 



168 



on his arms.On his arms. On asking his mother, she denied knowing the cause 
of the injuries. 

a) What do you cali his syndrome? How could you reach this diagnosis? 

(5 marks) 

b) How the physician could define the age of the contusions? Expalain. 

(3 marks) 

c) Are there any important investigations should be done in this case? 
Why? 

(3 marks) 

d) Do you think this child needs hospital admission or not? Explain. 

(4 marks) 

e) What are the complications of scalp injury? 

(6 marks) 



2) Give an account on: 

a) Difference between precipitated labour and homicidal injury of infant 

(6 marks) 

b) Medico legal importance of gun powder. (6 marks) 

c) Forms and validity of consent. (6 marks) 

d) Rapid causes of death in burns "within 6 to 48 hours" (6 marks) 



3) A 40 year-old male worker in a battery factory for ten years started to 
complain of repeated attacks of abdominal colic and constipation. On 
examination marked pallor was noticed. 

a) What is the probable diagnosis and why? (5 marks) 

b) Explain the pathophysiology (etiology) of the pallor present in this 
case. 

(5 marks) 

c) What are the investigations needed to confirm the diagnosis?(4 
marks) 

d) How could you treat this case? (7 marks) 

4) Give an account on: 

a) Defination and characteristics of drug dependence in general. (6 

marks) 

b) Clinical picture of botulism and its differential diagnosis. (6 

marks) 

c) Clinical picture of acute theophylline toxicity. (6 

marks) 
d) Contraindications and complications of activated charcoal. (6 

marks) 



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